Socioeconomic Disparities in Elderly Health Conditions in Europe. Transition Probabilities between Health Statuses.

Jeroen Spijker, Autonomous University of Barcelona (UAB)
Daniel Devolder, Centre of Demographic Studies (Barcelona)
Sarahí Rueda-Salazar, Centre d''Estudis Demogràfics (CED)

This study focuses on changes in the health status of people aged 65 and over living in Spain. The purpose of this research is to analyse how individual-level socioeconomic characteristics, living arrangement and household conditions have an impact on health status transitions of elderly. To this end, the aging context is explored through the health indicator related to the functional limitation “Global Activity Limitation Index” (GALI). Data come from the EU-SILC (EU Statistics on Income and Living conditions) panel survey as it represents a powerful instrument to analysis socioeconomic status in European countries at household and individual level in combination with different health statuses, including death. A Multi-State Model with recovery is applied to estimate transition probabilities among three different health states: Healthy, Not healthy and Death. There are six possible transitions from one state to another. The multistate approach allows us to estimate probabilities of change between health states and the expected occupation time in each state which is expressed in a similar approach as the life expectancy at a specified age but regarding health states.

Research questions will address whether living arrangement characteristics (as household size and residential arrangements) and household condition (ability to make ends meet, ability to keep home adequately warm, capacity to face unexpected finances) have an effect on health status transitions. We control for age, sex and educational attainment. Possible policy implications of our findings on social disparities in health among people aged 65 years and over will be discussed.

Severalstudies on differences in the health status of elderly have pointed out thathealth inequalities were largest in southern European countries, while Nordiccountries observed the smallest differences[1].They illustrated that factors such as educational attainment, livingarraignments, labor activity and also material deprivation as importantdeterminants of health status. However, less is known about how householdconditions affect health status among elderly. The research presented here is thereforean attempt to fill this gap. It is an exploratory study of how household conditionand living arrangements influence the functional limitation of people aged 65and over in Spain.

As the European elderlypopulation is heterogeneous in terms of health within the same age group wesplit the population into two sub-groups: ages 65-74 and 75+. The variables relatedto household level are divided into two set of covariates: Living arrangementsand household condition. Regarding the former we test the effect of householdsize and the residential arrangements living alone, living with partner/spouse,living with children and living with others. Regarding the latter, we analyse theeffect of the ability to make ends meet, to keep home adequately warm and the capacityto face unexpected finances.

Theforce of mortality also declines with increasing socioeconomic status at varyingintensities within regions and countries. Additional years of remaining lifeexpectancy were due to improvements in health and functional status of elderlypeople[2]. However, perhaps paradoxically, health status itself has not always followedthe same trends as this depends on the health dimension that is used, the timeunder analysis and the population covered. Empirical studies illustrate complexmechanisms interacting between mortality trends and the different dimensions ofhealth.

Thisstudy uses the GALI indicator which measures the socio-functional dimension of healthby capturing the activity limitation due to mental and physical impairment ofadults in population surveys. A functional limitation is described as theimpediment experienced by an individual in performing any activity. Data come from the EU-SILC(EUStatistics on Income and Living conditions) panel survey, which represents apowerful instrument to analysis economic and social status in Europeancountries at household and individual level in combination with differenthealth statuses, including death.

Forthe purpose of our study, we defined health states according to the followingclassification: Healthy, i.e. individuals who report not have a limitation inactivities due health problem; unhealthy, i.e. persons who reported having alimitation, including both options; strongly limited and limited; and, as theabsorbing state, death. This classification is similar to those used in manydisability models addressed to measure Healthy Life Expectancy.






We use multistate transition models asthey allow patterns of changes in any condition, including health status, to bestudied[3].The illness-death model is commonly used in the field of health for studying theprogression and recovery of diseases (see Figure 1), i.e. stability (nochanges), decline (a deterioration of the current heath state, taking intoaccount the previous one) and even improvement (recovery to a better healthstate).  Furthermore, these models allow testing the effect of risk factors, inour case household conditions and living arrangements, on changing healthstatus.


Van der Gaag[4] identified advantages and drawbacks inthis methodology. One advantage is that it takes into account the effects ofchanges in risk factors on specific disease or health conditions. The authors statethat when the probability of becoming disabled for obese people is greater thanthe probability of people without obesity (people with ‘normal’ weight), themodel could be used to project the effect of changes in the prevalence ofobesity on the prevalence of disability. Similarly, we will explore whetherchanges in living arrangements and conditions have an impact on the probabilityof suffering a functional limitation in daily activities.


Expected results: In an ageing contexthealth status can be considered to be a cause and consequence of variations in livingarrangements and household conditions. Both may affect health states inadvanced ages, but the inverse can also occur. For instance, a change in thehealth status, such as a recovery or deterioration in functional ability, maybring with them changes (for better of worse) in residential arrangements andhousehold conditions, even if the individual in question does not moveresidence. An example would be when someone becomes a widow. In this sense, forresearch purposes health status could be considered as both a dependent andindependent variable.

[1]Eikemo et al. (2008) Health inequalities according to educational level indifferent welfare regimes. Sociology of health & illness 30(4):565-582. 

[2] Crimmins(2004) Trends in the Health of the Elderly. Annual Reviewof Public Health, 25(1):79-98.

[3]Willekens(2014) Multistate Analysis of Life Histories.  Springer.

[4] Van der Gaag (2015) A Multistate model to project elderlydisability in case of limited Data. Demographic Research 32,75.

Presented in Session 1173: Health, Wellbeing, and Morbidity