Individual and Contextual Determinants of Inequalities in Health: The Italian Case (original) (raw)
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Journal of Public Health, 2018
Backgrounds The empirical evidence shows discordant results regarding the role of local contexts on individual health. This article considers the role of the municipal socioeconomic contexts on self-rated health in Italy, taking into account some individual variables. Methods Multilevel model software (MlwiN) is used to fit multilevel linear regression models of perceived health. Individual data are from the Italian surveys on BAspects of Daily Life^2010, 2011 and 2012, collected by the Italian National Institute of Statistics (Istat). In addition, municipality-level social, demographic and economic characteristics are from the 2011 Census and the database BAtlas of Italian Municipalities^(Istat). Results The main findings of this study confirm that, controlling for age and gender at the individual level, poor health is influenced by socioeconomic positions: lower education, not working or looking for employment and disadvantaged family social class predict higher perceived health. The individual level explains the 70.1% heterogeneity in self-assessed health, the family level 25.6% and the municipality level only 4.3%. The additional influence of the socioeconomic context is, conversely, of little substantive importance. Conclusions Finally, by showing that variability in health relates mainly to individual characteristics, this study suggests that intervention to mitigate social inequalities in health should focus on structural factors, such as education and the labour market.
Place of living and health inequality: a study for elderly Italians
2012
The aim of this study is to explore if the context matters in explaining socioeconomic inequality in the self-rated health of Italian elderly people. Our hypothesis is that health status perception is associated with existing huge imbalances among Italian areas. A multilevel approach is applied to account for the natural hierarchical structure, as individuals nested in geographical regions. Multilevel logistic regression models are performed including both individual and contextual variables, using data from 2005 Italian Health survey. We prove that individual factors (compositional effect), even representing the most important correlates of health, do not completely explain intra-regional heterogeneity, confirming the existence of an autonomous contextual effect. These territorial differences are present among both Regions and large areas, two geographical aggregations relevant in the domain of health. Moreover, for some Regions, the account for contextual factors explains variations in perceived health, leading to an overthrow of the initial situation: these Regions perform better than expected in the field of health. For other Regions, the contextual elements introduced do not catch the milieu heterogeneity. In this regard, we expect, and solicit, a major effort toward data availability, qualitatively and quantitatively, that might help in explaining residual territorial heterogeneity in health perception, a fundamental starting point for targeting specific policy interventions.
Research in Social Stratification and Mobility, 2018
In the literature there is a lack of investigation on health inequalities in South America and their differences with respect to those in the developed countries. Since Italy has recorded similar economic trends in recent years and has some similarities with Argentina, we decided to use the Mediterranean country for comparative purposes. Our hypothesis was that, beyond structural differences, health inequalities present similar patterns in these two countries characterized by a capitalist economy. Social groups in advantaged educational and occupational positions exhibit better health than disadvantaged groups. We present some descriptive statistics on the overall situation in the two countries, and we then analyse data stemming from two surveys that collected individual information on social conditions and health statuses (OASD from 2010 to 2015, and "Multiscopo-Health condition and use of health services", ISTAT 2013). The findings show that Argentina and Italy have different levels of wellbeing, mortality rates, and health services. But relative disparities in health seem very similar, confirming the hypothesis of Marmot (2017) about the general form of health inequalities. Manual and precarious workers (in particular unemployed persons) present systematically worse perceived health with respect to higher social classes.
International Journal of Occupational and Environmental Health, 2005
To evaluate differences in mortality by social class and to determine the impacts of socioeconomic factors on health inequalities in Italy, mortality data from 1981-2001 were analyzed as a function of social class in Turin, controlling for occupational risks, housing conditions, and education. For general and cause-specific mortality, the weight of each socioeconomic indicator was evaluated on population-attributable fraction to social class. Among men, mortality risk was significantly higher in unskilled blue-collar workers (RR = 1.45). Among women, the differences by social class were slighter. Education and economic status mostly explain the mortality differences by social class in men, while economic status showed the highest contribution in women.
Mortality amenable to health care services and health inequalities across the regions of Italy
European Journal of Public Health, 2020
Background Amenable mortality is an indicator that measures the extent to which health services contribute to the improvement of the health of a population. It can also highlight geographical and socioeconomic inequalities. Therefore, it is used to assess quality and performance of health care systems, both at national and subnational level. The Italian National Health Service sets the essential levels of care (Livelli Essenziali di Assistenza, LEA), a health-benefit package for all citizens. Because every region is responsible for providing the LEA and can offer additional health care, monitoring the performance of the Regional Health Services (RHSs) is of increasing interest. Methods We used Nolte and McKee's list of amenable conditions to analyze the temporal trend of the standardized mortality rate (per 100.000) in Italy from 2006 to 2015, overall and by gender. We also examined the standardized rate at regional level by comparing the two-year periods 2006/7 and 2014/5, over...
Material and social deprivation in Italy: an analysis on a regional basis
Business and Economics Journal, 2016
The existence of an inverse association between socioeconomic status and the incidence of most diseases is well-established in literature: higher rates of morbidity and mortality have been reported among lower socioeconomic groups in many European countries. However, it’s an open question which component of socioeconomic status affects health most, and how that relationship should be measured. The relation between socioeconomic factors and health inequality may be proved at the individual level, or at the geographic-area level. In this paper we follow the second stream of literature, i.e studies on deprivation relating the state of disadvantage suffered by an individual, with the living conditions of the area where the individual resides. The aim of this study is to measure two different conceptions of deprivation, in order to develop two different indicators of deprivation: the first concerning material deprivation, through the study of direct variables, and the second related to s...
BMC Public Health
Background: Self-rated health is widely considered a good indicator of morbidity and mortality but its validity for health equity analysis and public health policies in Italy is often disregarded by policy-makers. This study had three objectives. O1: To explore response distribution across dimensions of age, chronic health conditions, functional limitations and SRH in Italy. O2: To explore associations between SRH and healthcare demand in Italy. O3: To explore the association between SRH and household income. Methods: Cross-sectional data were obtained from the 2015 Health Interview Survey (HIS) conducted in Italy. Italian respondents (n = 20,814) were included in logistic regression analyses. O1: associations of chronic health conditions (CHC), functional limitations (FL), and age with self-rated health (SRH) were tested. O2: associations of CHC, FL, and SRH with hospitalisation (H), medical specialist consultations (MSC), and medicine use (MU) were tested. O3: associations of SRH and CHC with household income (PEI) were tested. Results: O1: CHC, FL, and age had an independent summative effect on respondents' SRH. O2: SRH predicted H and MSC more than CHC; age and MU were more strongly correlated than SRH and MU. O3: SRH and PEI were significantly correlated, while we found no correlation between CHC and PEI. Conclusions: Drawing from our results and the relevant literature, we suggest that policy-makers in Italy could use SRH measures to: 1) predict healthcare demand for effective allocation of resources; 2) assess subjective effectiveness of treatments; and 3) understand geosocial pockets of health inequity that require special attention.
Social mobility and health in the Turin longitudinal study
One of the most controversial explanations of class inequalities in health is the health selection hypothesis or drift hypothesis which suggests there is a casual link between the health status of individuals and their chances of social mobility, both inter- and intra-generational. This study tests this hypothesis, and tries to answer three related questions: (a) to what extent does health status influence the chances of intra-generational mobility of individuals? (b) what is the impact on health inequalities of the various kinds of social mobility (both mobility in the labour market and exit from employment)-do they increase or reduce inequalities? (c) to what extent does health-related intra-generational social mobility contribute to the production of health inequalities? The data analysed in this paper were drawn from the records of the Turin Longitudinal Study, which was set up to monitor health inequality of the Turin population by combining census data, population registry records and medical records. Occupational mobility was observed during the decade 1981-1991. To evaluate the impact of the various processes of social mobility on health inequalities, mortality was observed over the period 1991-1999. The study population consists of men and women aged 25-49 at the beginning of mortality follow-up (1991), and registered as resident in Turin at both the 1981 and the 1991 censuses (N = 127,384). Health status was determined by observing hospital admission. For the purpose of the study healthy individuals were those with no hospital admissions during the period 1984-1986, while those admitted were classed as unhealthy. Social mobility in the labour market was measured via an interval data index of upward and downward movements on a scale of social desirability of occupations, designed for the Italian labour force via an empirical study carried out by de Lillo and Schizzerotto (La valutazione sociale delle occupazioni. Una scala di stratificazione occupazionale per l'Italia contemporanea, Il Mulino, Bologna, 1985). Movement out of the labour market was described by a discrete variable with four conditions: employed, unemployed, early retired and women returning from work to the housewife status. The relationship between health status and occupational mobility was analysed via analysis of variance and multinomial logistic regression. Health inequalities were measured by the ratio of standardised mortality rates in the unskilled working class and the upper middle class. The study found a weak relationship between health status and occupational mobility chances. Decidedly stronger was the impact on occupational mobility of gender, education and "ethnicity" (being born in the South of Italy). The relationship between occupational mobility and health takes two different forms. Occupational mobility in the labour market decreases health inequalities; occupational mobility out of the labour market (early retirement, unemployment, housewife return) widens them. The maximum contribution health-related intra-generational social mobility can make towards health inequalities was estimated at about 13% for men.
Health status and quality of care in the Italian Regions
2011
The Italian Observatory on healthcare report (Rapporto Osservasalute-RO) is divided into two parts, the first dealing with population health and needs and the second describing regional health systems and quality of services; it aims to make available objective and scientifically rigorous data to those responsible for decision-making in order to help them taking appropriate, rational and timely actions in favour of target populations' health. The data analyzed in the RO 2010 highlight the continuing consolidation of Italians' health, which is generally good, but underline the progressive increase of macro-areas, regional and gender inequalities. These differences also emerged as of the regional health systems performance and are the most concerning because, in some regions, the failure or delay in the reorganization of health services according to demand, was not able to adapt its local supply with respect to specific demographic and epidemiological characteristics of the resident populations; this means that conditions of inadequate health care persist or even worsen, with the Southern Regions being in clear disadvantage compared to Central and Northern regions. In some regions, indeed, the resident population demand is adequately met by supply and quality of services provided, while in others, the health services available are inadequate and sometimes unfit to meet the users' demands. This probably depends on the lack of rational planning, organizational and management choices, and on the impact of the economic crisis that hit our Country. The need and, in some cases, the urgency for action by all the institutions of the sector is evident, both nationally and regionally, in order to avoid or at least try to mitigate the widening of the health differential and ensuring all citizens, regardless of place of residence and socioeconomic status, adequate and equitable health care. Moreover, a good and wise health planning would ensure citizens not only a better health status, but also a more solid economic and social holding in their own region. The report is structured as follows:-96 Core Indicators: describing the essential aspects of the Italian health and health services in all regions even through the use of charts, graphs and cartograms.-11 Boxes: in which examples of good practices experienced in some regions and possibly ready to be adapted to other regions, are proposed-11 Insights: where some overriding problems are discussed in detail in order to outline possible solutions and that, since the previous edition, have been published on the website: www.osservasalute.it. FIRST PART-Population health and needs Population-In order to assess health services demand and to upgrade the local supply with respect to demographic differences, data on the population dynamics have been updated (2008-2009) and analyzed, with sections devoted to migratory components that, over time, may modify the populations genetic and nosological patrimony, to fertility and population structure, with particular reference to the "elderly" (65-74 years) and "frail elderly" (75 years and over) that are the most exposed at risk of serious and disabling diseases and death. The indicator regarding the proportion of elderly people living in a single family nucleus on the total population of the same age was also reiterated and showed that, in 2008, 27.8% of those over 65 lived alone (+0.7% compared to 2007) and that women are the majority. At national level we can find an increasing trend of resident population mainly due to the growth of the migration component. The examined indices show the same trends highlighted in the previous years, confirming: the positive net migration thanks to, above all, the attractiveness of the Centre-North; the positivity of net migration with other countries, even if the value is lower than the previous two years (2007-2008), that still sees the Northern and Central regions most affected by the phenomenon; the continuous internal migration across the Country involving more Southern regions (excluding Sardegna and Abruzzo), in particular Campania and Basilicata. Even this year, a slight recovery for the total fertility rate (TFR) has been found, even though the values are extremely low (1.42 children per woman in 2008) and below the ratio (about 2.1 children per woman) that would ensure the generational replacement. This recovery is partly due to both an increase in fertility of older women (over 30 years) and the proportion of births from foreign mothers (an increase of +1.3 % compared to 2007), particularly in Centre-North regions. Regions that continue to be characterized by a very low TFR are Sardegnia and Molise (respectively 1.11 and 1.17 children per woman). The mean age of mothers giving birth is basically stable as the national value in 2008 amounted to 31.1 years (an increase of 0.7 years compared to 2000). Sardegna in particular, presents a value that is one year higher than the one recorded for Italy as a whole, while Sicilia, with a value of 30.3 years, is the region in which, however, the mean age at childbirth is the lowest. The knowledge of these indicators related to fertility allows a more effective organization of health facilities, such as, for example, specialized services for the monitoring of pregnancy and childbirth assistance. As for other demographic features, the main characteristic of our Country is the strong tendency to aging (1 person aged 65 and over every 5 residents and about one person of 75 years and over every 10 residents); the region that has been holding for years the record as the "oldest" Italian region is Liguria, while the youngest is Campania, where population aging is in a less advanced stage. The ratio between the number of men and the number of women, an imbalance in favor of women has been seen so that they enjoy a higher survival. To be highlighted is the presence of foreign residents in between youth and middle age classes.