Demographic change and the evolving demands on healthcare systems, especially in the
provision of healthcare and long-term care for a growing number of older people, are
among the greatest social challenges of the next decades. This is particularly true
for the WHO European region that includes 9 of the 10 countries with the longest life
expectancy globally. The pursuit of health equity in ageing societies raises several
questions: On the one hand, there is persisting health inequities that are related
to a social gradient in health, in and between countries. On the other hand, as resources
are scarce, social challenges to healthcare and the healthcare system will always
entail questions of distributive justice. This is even more important as the fair
and effective functioning of health care and social systems is of particular relevance
to older people, who carry a much higher overall burden of disability than, for example,
middle-aged population groups. Most of the health problems of older age are related
to chronic diseases, and this underlines the role of prevention and health promotion
throughout the life course to help reduce this burden due to non-communicable diseases
[1]. However, the feasibility and effectiveness of health promotion interventions
for seniors often remain unclear. New avenues of intervention delivery, e.g., through
ehealth approaches are an active area of research at present (e.g., [2]), and overall
the topic of ageing and health has become a major Public Health research field over
recent years.
At the University of Bremen, interdisciplinary Public health and Nursing researchers
working in the high profile research area Health Sciences organized a two-day conference
in June 2017 to discuss issues of ageing, health, and equity. The conference covered
preventive as well as health service and long-term care aspects, and also discussed
training and qualification of healthcare professionals. We were interested to understand
more deeply health problems of the elderly as well as potential solutions, and in
particular which societal and social system aspects or interventions contribute to
or alleviate inequalities and/or strengthen equity. While there was a clear empirical
focus, new insights into theories, concepts, and research methods were welcome. Conference-related
as well as additional manuscripts were then submitted and reviewed for this special
issue of the IJERPH. The special issue includes three focus areas: (i) methods-oriented
approaches, (ii) social inequality and health among the elderly and inequality in
the utilization of long-term care, and (iii) the health status of and service provision
for people in need of long-term care.
1. Methods-Oriented Approaches
A methods-oriented approach to specific health and healthcare topics among the elderly
is presented by papers from Dorant and Krieger [3], Schilling and Gerhardus [4], and
Bunt et al. [5].
Dorant and Krieger [3] conducted participatory health research to explore and improve
a family caregiver support program, with care professionals acting as co-researchers.
Long-term care is predominantly provided in the home setting, with strong involvement
of family members. The family caregiver support system is aptly considered as a complex
intervention in the geriatric setting, and the many professions that are involved
in geriatric care are considered as (still learning) experts also for research development
and conduct. The authors provide first insight into processes of research co-creation
in the geriatric setting, with a focus on the involvement of service providers. As
further step in participatory health research, all of the stakeholders, including
actual family caregivers, and eventually service recipients, might be included, but
this needs other careful preparatory steps.
This is the topic of Schilling and Gerhardus’ [4] work who start with the premise
that “little is known about how to involve older people” in health research. In their
review of methods for involvement of older people in health research they finally
included 9 studies from the UK, all but one focusing on people with dementia. Overall,
the authors conclude that research involvement of seniors is feasible, but very careful
consideration has to be given to issues, such as the research setting, appropriate
communication, and limits in mobility, as well as self-confidence and trust among
the elderly with age-related health problems.
Some of these restraints are also covered by the concept of social frailty, which
describes the different stages of loss of social resources, abilities, and activities
that are relevant to fulfill basic social needs. Research needs proper instruments,
and Bunt et al. [5] provide detailed insight into the cross-cultural adaptation of
a specific tool, the Social Vulnerability Index, for use in the Dutch context. Through
several Delphi rounds, the translated instrument was adapted and then tested in a
small sample of older adults. While its use was generally shown to be feasible, marked
heterogeneity in the application time between two experts using the instrument highlights
one of the remaining challenges, and more experience with measuring and understanding
social frailty is clearly needed. This includes a full assessment of psychometric
properties of the index.
2. Social Inequality and Health among the Elderly and Inequality in the Utilization
of Long-Term Care
The papers of Nazroo [6], Hoebel et al. [7], Schönbach et al. [8], and Schoenmakers
et al. [9] focus on social inequality and health among the elderly, alternatively
investigated under a class or ethnicity-cultural lens.
James Nazroo [6] uses data from the English Longitudinal Study of Ageing (ELSA) to
carefully analyze inequality in the post-retirement period. He puts a focus on healthy
life expectancy and its variation across levels of socioeconomic position. A beauty
of the available data from ELSA lies in the diversity of measures both regarding socioeconomic
inequality and health and wellbeing. Nazroo then draws on Bourdieu for a theory-grounded
(and life-phase adequate) assessment of causal mechanisms relating class with health
and wellbeing in later life. He notes high risks of moving into social detachment
among the least affluent, which in turn is related to markedly poorer health.
For Germany, Hoebel et al. [7] analyse inequalities and perceived unmet needs among
participants of the German Health Update study aged 50–85 years. Their analysis indicates
that the socioeconomic differences in health remain present across the age-range,
but appear to narrow at older ages and more so among men then among women for several
of the self-rated aspects considered. The different potential explanations put forward,
including selective survival and the age-as-a-leveler hypothesis, make an interesting
read and stimulate critical discussion.
Schönbach et al. [8] provide deeper insight into an example of health-related behavior
and show that physical activity as a key factor of healthy aging, measured as sports
participation, takes a positive leap at entry to retirement, but social differentials
remain. A migrant background as well as the level of acculturation only had minor
effects on the enhanced post-retirement physical activity levels in this analysis
of German Socio-Economic Panel data.
One import factor for prevention as well as physical and mental health care is the
availability of social networks. What exactly this role might be with respect to access
to psychosocial care for migrant populations in the Netherlands is the topic of Schoenmakers
and coauthors’ work [8]. Their qualitative study highlights the role of children in
navigating towards psychosocial care. It also shows that social networks of elderly
migrants are generally not sufficient to adequately support psychosocial needs, and
sometimes contribute to stresses and worries. Enabling factors include, good language
proficiency and good mental health literacy of individuals and their networks, among
others.
3. Health Status of and Service Provision for People in Need of Long-Term Care
Inequality in the utilization of long-term care and the health status of residents
of nursing homes are analyzed by Jacobs et al. [10], Ilinca et al. [11], and Frisina
Doetter and Schmid [12].
Physical frailty in old age results in hip fractures with disproportionate frequency
as age increases. Jacobs et al. [10] investigate hip fracture frequency and determinants
among nursing home residents and confirm a markedly increased risk during the immediate
time period after first admission to the home. Incidence rates for women were 20%
higher than for men. It seems hard to conceive active preventive measures for this
problem, but clearly a heightened awareness of nursing home staff during the first
months of new residents is warranted.
Long-term care arrangements become more and more important in European countries.
Ilinca et al. [11] analyze inequality and inequity among older European populations
with respect to home care. SHARE data from 2013 are analyzed using the Concentration
Index, a measure of health inequality related to socio-economic status, and further
decomposition of explanatory factors. The authors can show that use of long-term care
differ between income groups within countries even after controlling for care need,
with poorer households using more long-term home care. They highlight the importance
of clear definitions with respect to need factors as differences in definition—as
shown in the paper—lead to contradictory results.
If the need of long-term care is so high that families can no longer cope with it,
traditionally, nursing homes have been the only alternative. When the mandatory long-term
care insurance was founded in Germany in 1994, its major benefits were cash payments
to (partly) compensate family care-givers, in kind benefits that might support family
care-givers and benefits for nursing home care. If home care is not or no longer possible,
nursing home care once again seems to be the natural alternative. In the last decade,
however, the interest in innovative care models that provide more choice and flexibility
to beneficiaries has increased. Frisina Doetter, and Schmid [12] examine one kind
of alternative, i.e., ‘shared housing’, where a small group of people rent private
rooms, while sharing a common space, domestic support, and nursing care. Based on
interviews and secondary data, they analyze in how far such new forms of care provision
may provide an alternative to nursing home care for a larger population of beneficiaries
than presently seen in Germany, thus increasing equity.
4. Synthesis, Conclusions, Research Needs and Opportunities
The contributions to this special issue have commonalities in their consideration
– at different levels—of socioeconomic factors shaping health in advanced age. In
some cases, life events including retirement or the need of long-term care or admission
to a nursing home, are the cornerstone shaping subsequent health-related dynamics
or occurrences, in other cases, the perspective centers on larger age groups and their
comparative health and social status. These approaches alone provide for multiple
different insights into the health and health needs of ageing populations and service
provision to them. The special issue additionally gives exemplary guidance on many
different data sources and research methods that can be used in this field, and the
involvement of caregivers as well as the elderly themselves in research is likely
to be both challenging and necessary for increasing relevance and transferability
of research findings in day-to-day settings. Careful reading of the papers in this
issue also brings to light two further messages: socioeconomic differentials in health
relevant for older age are taking their course much earlier in life, but they continue
to be dynamic. Also: ageing and retirement brings new opportunities, be it in terms
of changing physical activity levels or of active social engagement, which may also
include participation in Public Health research on ageing, health, and equity.