Διερεύνηση της ευεξίας και της χρήσης υπηρεσιών υγείας των ηλικιωμένων ατόμων στην Ελλάδα και την Ευρώπη
Authors: Βοζικάκη Μαρία 
Published: September 2021

Background The fact that the contemporary world has been ageing rapidly is one of the greatest challenges health care and social security systems have to deal with. Social and gerontological research that has been implemented up to date, mainly at the country level, has extensively addressed the health of people of third and fourth age and has thus indicated several determinants associated with their social environment. In this context, well-being has been denoted to predict longer survival among older people and higher utilization of health care services. Therefore, well-being has become an important objective of ageing-related public health and social policies. However, the study of older adults’ well-being and the comprehensive evaluation of the factors related to its configuration remain relatively unexplored, whereas the respective existing findings of nationally comparative research have been limited.Aim The current study aimed at assessing the prevalence of six different positive well-being outcomes and their accumulated presence (4+) as well, among adults aged 65 years of age and older of the eleven European countries who took part in the first wave of the SHARE survey (Survey of Health, Ageing and Retirement in Europe), according to: (i) their socio-demographic characteristics, (ii) social engagement (1st Chapter), social isolation (2nd Chapter) and loneliness (3rd chapter). Furthermore, frequency of feelings of loneliness was examined in relation to adverse health conditions, stressful life events and social isolation (4rth Chapter). In addition, the utilization of preventive health services was measured according to social isolation indicators and their multiple clustering (5th Chapter). Lastly, we were interested to study the potential differences in well-being, social engagement, social isolation, loneliness and preventive health services utilization among the different countries and geographical regions under scrutiny.Subjects and Methods The data of the present study pertains to a subsample of adults aged 65 and older which was retrieved from the first wave of the cross-national longitudinal SHARE survey which was conducted between 2004 and 2005 in eleven European countries (Austria, Belgium, France, Germany, Denmark, Switzerland, Greece, Spain, Italy, the Netherlands and Sweden). This survey was organized and coordinated centrally at the Mannheim Research Institute for the Economics of Ageing (MEA, Germany) under the collaborative effort of multidisciplinary national teams of more than 150 researchers worldwide and more than 60 working groups, including the research team of the Department of Social Medicine, in the Faculty of Medicine of University of Crete. The target population of the study concerned households with at least one member aged 50 and over, including their probably younger partners or spouses, and it was selected according to the complex multistage stratification design that was implemented so that this population to be representative of the European population aged over 50 years. At the individual level, the average weighted response rate which was achieved ranged from 73.7% in Spain to 93.3% in Germany, whereas at the household level the lowest response rate was reached in Switzerland (38.8%) and the highest in France (81.0%). For the purposes of the current investigation, the analyses comprised individuals aged 65 years and older within the SHARE sample, which yielded a study population of 7,025, 5,129, 5,074 and 6,971 respondents. Well-being was gauged as the clustering of six indicators: quality of life, depressive symptomatology, self-perceived health, life satisfaction, chronic conditions and Body Mass Index (BMI). High well-being was equated with reporting high quality of life, exhibiting absence of depressive symptomatology, perceiving health status as very good, being very satised with life, suffering from one or none chronic health condition and having normal BMI. The clustering of more than four well-being indicators (4+) was considered to be indicative of higher well-being and referred to as multiple presence of positive well-being outcomes. Additionally, we assessed the socio-demographic characteristics of the participants, their social engagement, social isolation, loneliness, adverse health conditions, stressful life events and preventive health services utilization. Data were analyzed using the IBM-SPSS v21.0. Weights were applied according to the complex sampling design of the study, reflecting non-responses and stratification design. The prevalence of well-being indicators and the respective 95% confidence intervals (95% CIs) were estimated according to the complex sampling design. Furthermore, analysis of covariance and multivariate regression analysis were applied in order to search for potential differences and associations between well-being and social engagement, social isolation and loneliness. Furthermore, we estimated frequency of feelings of loneliness with the respective p-values and we examined frequency of loneliness according to adverse health conditions, stressful life events and social isolation. Multivariate regression models were calculated with the respective Odds Ratios (ORs) so as to study the effect of the above factors on frequency of loneliness. Lastly, preventive health services utilization was measured according to a composite score of twelve different items (12-item composite score) and the distribution of this score was investigated according to social isolation. In addition, the utilization of the distinct components of preventive care under study was also examined according to different indicators of social isolation through multiple logistic regression analysis. Moreover, in order to detect possible national variations, we estimated the weighted prevalence and the corresponding confidence intervals of the frequency of lacking indicators of well-being and the occurrence of social isolation and loneliness across the eleven SHARE European countries. Lastly, country-specific differences in the association between the frequency of activity participation and well-being clustering were also addressed by means of simple linear regression analysis. Results More than four indicators of well-being were observed for 10.2% of the respondents, whereas for 14.4% of the total sample no positive well-being outcomes were rendered. The majority of the sample was found with one or two well-being indicators (28.9 and 27.9%, respectively). The presence of 4+ wellbeing indicators was signicantly more common among participants aged 65–74 years than among those of age 75–84 years, whereas the prevalence of accumulated well-being indicators among the oldest-old participants of the study did not differ signicantly from the their younger counterparts aged 75-84 years old. The prevalence of 4+ well-being indicators was shown to be more than twice as high (23.2%; 95% CI 20.5–26.1) in Northern countries compared to Central countries (11.2%, 95% CI 9.7–12.8) and more than three times as high compared to Southern ones (7.2%; 95% CI 5.8–9.0). A significantly lower proportion of the participants who had not participated in any productive or/and social activities were found with high quality of life, in relation to productively and socially active ones. Likewise, the proportion of adults who were attested with low depression score, rated their health as very good, were very satisfied with life and displayed less than two chronic diseases was significantly higher among those with frequent productive or/and social activity participation over the course of the previous month.This pattern was consistent for most well-being indicators and remained after their clustering, with 4+ indicators of well-being being signicantly more prevalent among frequent participants in productive or/and social activities, than infrequent ones (15.0%, 95% CI 12.9–17.4 vs. 7.2%; 95% CI 6.1–8.5). Clustering of well-being indicators was found to correlate at a signicant level with frequent participation in productive (ORs=1.35, p=0.007) and social activities (ORs=1.57, p<0.001). Accordingly, a higher score of well-being indicators was evident among older adults participating frequently in productive or/and social activities, in relation to those who had not participated in any activities over the course of the previous month (2.1 vs. 1.7, respectively, p<0.05). The correlation between frequent productive or/and social activity participation and multiple presence of well-being indicators was 0.050 (p=0.045).Additionally, well-being was found to be significantly associated with specific indicators of social isolation. More particularly, individuals contacting their offspring daily or at least once a month displayed a significantly higher mean well-being score (1.80), in relation to those reporting less frequent or no parent-child contact (1.40) (p=0.028). The above pattern was also ascertained regarding participants with at least one social activity, in relation to their socially inactive peers (1.93 vs. 1.70, p=0.001). A higher mean well-being score was thus observed among older adults living in partnered households (1.90), compared to their unpartnered counterparts (1.69) (p=0.007). Older individuals with an accumulation of social isolation indicators indicated a lower mean well-being score (1.69), in comparison to the least isolated individuals (1.94). However the above difference did not reach statistical significance (p=0.200).Regarding the prevalence of well-being outcomes according to loneliness, it was found that individuals who declared feeling lonely most of the time over the course of the previous week had a significantly lower mean score of indicators of well-being (1.07), relative to their non lonely counterparts (1.36) (p-trend=0.002). Moreover, the proportion of the respondents being very satisfied with their life was significantly higher among those with no feelings of loneliness (40.5%; 95% CI 38.1-42.9), as compared to adults with very frequent endorsement of loneliness feelings (10.5%; 95% CI 7.1-15.3). Likewise, multiple clustering of well-being indicators was significantly more prevalent among non lonely individuals (15.5%; 95% CI 13.8-17.2), in relation to their lonely seniors (6.9%; 95% CI 3.7-12.4).As far as the assessment of loneliness is concerned, persistent feelings of loneliness, endured most of the time, were mostly reported by females (11.2%), compared to males (7.2%), whereas frequent feelings of loneliness were reported by 30.8% of males and 47.9% of females (p<0.001). In addition, loneliness was indicated to be unequally distributed among different age groups and individuals of different educational and income status. Specifically, the proportion of individuals declaring to feel lonely most of the time was significantly higher among the oldest-old participants (85+) (12.4%), as compared to their younger counterparts, aged 65-74 (7.7%) and 75-84 years old (11.9%) (p<0.001). Moreover, older adults who had obtained more years of schooling were found to suffer from significantly less frequent feelings of loneliness, in comparison to adults with the least years of education (p<0.001). Likewise, 13.6% of the respondents with the lowest household income declared to feel lonely, in relation to 7.3% of those belonging to the highest income quartile. As regards the association of loneliness with adverse health conditions, stressful life events and social isolation significant differences were shown to exist. More particularly, individuals with one or more chronic conditions reported more frequent feelings of loneliness, in comparison to adults suffering from less than two chronic diseases (p=0.015). This pattern also held true for older people with more than one limitations in activities of daily living ((I)ADL) (p<0.001) or more than one disease symptoms (p=0.002) and more than four depressive symptoms (p<0.001). Furthermore, significant were the differences noted in the distribution of loneliness frequency between individuals living in social isolation, as indicated by solitary living, social disengagement and childlessness (p<0.001). In addition, for 12.2% of widowed older people frequent feelings of loneliness were endorsed, relative to 7.8% of those living in partnered households. In a similar vein, the likelihood of persistent endorsements of feelings of loneliness was twice as high among older adults whose offspring had recently moved out from parental nest, in relation to those whose child still shared the same house with them, in both models of multiple logistic regression analysis (ORs=2.08; 95% CI 1.24-3.48 and ORs=1.75; 95% CI 1.03-2.96, respectively). Lastly, 27.8% of Italian and 26.1% of Greek older individuals were categorized as severely lonely, which applied to 6.0% of the elderly in Denmark and 5.0% in the Netherlands. With reference to the utilization of preventive care according to social isolation, the mean score of preventive health services was documented to be significantly higher among adults residing with a partner or spouse (p=0.001), being married (p=0.004), having at least one child (p=0.046) and being involved in any kind of productive or/and social activity (p=0.023). Additionally, respondents presenting multiple presence of social isolation indicators (4+) were found to have a significantly lower mean score of preventive health services utilization, as compared to their non isolated partners (37.6 vs. 41.8, p=0.046). Further, older adults living unpartnered, as well as those being socially disengaged, indicated a significantly lower likelihood to have visited a dentist (ORs=0.69; 95% CI 0.52-0.91 and ORs=0.70; 95% CI 0.54-0.89, respectively). Similarly, individuals with no activity participation had lower odds of having ever undertaken sigmoidoscopy or colonoscopy (ORs=0.74; 95% CI 0.57–0.96). Significant differences were discernible between the eleven European countries under investigation as regards the distribution of health services utilization score among socially isolated older people. Specifically, the mean score of preventive health services utilization among adults with 4+ social isolation indicators was 49.6 in France and 26.0 in Greece. Furthermore, the rate of the multiple presence of social isolation indicators was approximately 9.0–22.0% in southern Europe, relative to 13.0–25.0% among older people in northern and central Europe. Moreover, the proportion of adults being identified with more than 4 indicators of social isolation was the highest in Sweden (25.2%) and the lowest in Greece (8.8%). Conclusions According to the afore-mentioned cross-national empirical findings the social factors under study were found to be significantly associated with specific positive well-being outcomes and their multiple clustering, as well. In addition, preventive health services utilization was significantly related to different indicators of social isolation. The main conclusions that could be drawn are as follows: (i) well-being outcomes are socially distributed, with individuals with the least years of education and the lowest household income level being ascertained with the lowest likelihood of presenting multiple clustering of well-being indicators, (ii) well-being dimensions are differently distributed among the eleven European countries and the three geographical regions under investigation, which is in accordance with the well-established well-being “north-south pattern”, with significantly better outcomes being consistently attested among Northern Europeans, (iii) frequent productive and social activity participation is significantly related to well-being, (iv) specific elements of people’s social environment which pertain to social isolation are significantly related to well-being outcomes, (v) preventive health services utilization is associated with social living conditions and social isolation, (vi) non lonely older adults present better well-being outcomes and have a greater well-being mean score, whereas multiple clustering of well-being indicators seems to be less common among individuals declaring to feel lonely most of the time, (vii) frequency of reporting feelings of loneliness is significantly related to specific adverse health conditions, stressful life events and social isolation indicators and, (viii) recent departure of the last offspring from parental nest was the most significant independent predictor of loneliness.It becomes evident from the above findings that there seem to be specific factors of older people’s social and family context which are significantly associated with their level of well-being and can possibly hold beneficial implications for multiple well-being aspects. Several of these factors could be subjected to modification through to suitable interventions which could lead to the amelioration of individuals’ well-being as they age. Particularly, the enhancement of chances for active engagement in social activities and the encouragement of an active lifestyle could be to the benefit of older people’s well-being and respective strategies should therefore be oriented towards satisfying their needs for social integration and meaningful social connections. In addition, social and public health policies aiming at the improvement of later-life well-being ought to prioritize the mitigation of psycho-social distress and human pain which is reflected on the occurrence of loneliness as a key risk factor for health and well-being. Furthermore, the current results afford important empirical evidence on identifying factors which possibly bear upon social engagement, social isolation and loneliness and could thus extend current knowledge and understanding on well-being promoting factors and risk factors for poor well-being outcomes in old age.