Original articleHealth Inequalities among Older Adults in Spain: The Importance of Gender, the Socioeconomic Development of the Region of Residence, and Social Support
Introduction
Population ageing was among the most distinctive demographic events of the twentieth century and is expected to remain important throughout the twenty-fist century. According to the United Nations’ population prospects for 2050, 16% of the world population will likely be 65 years or over (United Nations, 2010). In Spain, this segment of the population is expected to represent 30% of the population in 2060 (IMSERSO, 2009). Because of their higher life expectancy, women account for the majority of older persons in the world (54% of the population aged ≥60), especially among the oldest-old, that is, those aged 80 or over (63% of the population aged ≥80 and 81% of the population aged ≥100; United Nations, 2010). These demographic tendencies have placed the analysis of health inequalities among the elderly as a priority in public health, although research on this topic is still scarce.
Health inequalities derive from the existence of inequalities in other domains of life, such as political, economic, and social spheres (Peter & Evans, 2001). Although research about health inequalities in Spain is relatively new, various studies carried out during the last decade show the existence of health inequalities associated with income inequalities, poverty, unemployment, illiteracy rates, and other social indicators in the adult population (Benach et al., 2006; Rodríguez-Sanz et al., 2007). The pattern found in these studies shows an unequal distribution of mortality, life expectancy, and poor self-rated health status, regions with higher poverty rates and income inequalities presenting poorer outcomes, that is, those in the south and northwest, and especially among women. For instance, Castilla y León and Navarra (in the North) presented a life expectancy of more than 77 and 84 years for men and women, respectively; whereas on the other extreme Andalusia and Canarias (in the South) had a life expectancy lower than 76 and 82 years for men and women, respectively (Rodríguez-Sanz et al., 2007). Similar regional differences in health have been found in Italy (Costa, Caiazzo, Marinacci, & Spadea, 2004).
Beyond regional inequalities in health, family roles and the sexual division of domestic work constitute important determinants of health status and of gender inequalities in health. One of the questions research about gender inequalities in health tries to answer is why women live longer than men and at the same time present a higher functional impairment (Arber & Cooper, 1999). That family demands are positively related to poor health status among women, but especially among those of less privileged socioeconomic positions, constitutes one of the main findings of this line of research (Artazcoz, Borrell, Benach, Cortès, & Rohlfs, 2004; Artazcoz, Borrell, & Benach, 2001), a finding that has also been found among older adults (Rueda & Artazcoz, 2009).
When studying the Gender Development Index (GDI),1 Carrasco-Portiño and her collaborators (2008) do not situate Spain in a very disadvantaged position compared with other European countries, but do describe important regional differences within the country. The north–south gradient described regarding socioeconomic inequalities in Spain is also found regarding gender inequalities. Whereas Navarra and the Basque Country showed the highest GDI, Andalusia and Extremadura presented the lowest ones in the two periods analyzed, 1990 and 2000. This and other studies, however, show a trend toward convergence in gender inequalities among regions in Spain, a faster convergence than that of the Human Development Index2 (Carrasco-Portiño, Ruiz-Cantero, Gil-González, Álvarez-Dardet, & Torrubiano-Domínguez, 2008; Domínguez & Guijarro, 2005). Despite the interest in studying gender inequalities in health, in Spain there is a lack of regional comparisons regarding this topic (Borrell, García-Calvente, & Martí-Boscà, 2004).
Social support is related to the individual socioeconomic position, to the social construction of gender, and to age. The association between social support and health has been described as varying by socioeconomic position, with working class individuals being more isolated than non-working class ones (Oakley & Rajan, 1991). Regarding the social construction of gender, some studies have found that whereas men tend to maintain less emotional relationships and are less embedded in their social networks, women’s relationships focus more on intimacy and women tend to provide and receive more support from members of their network (Kawachi & Berkman, 2001; Shye, Mullooly, Freeborn, & Pope, 1995). As people age, the type and amount of social support received and provided changes, with losses, but at the same time, the inclusion of new ties. A positive association between social support and both physical and psychological health among older adults is described in the literature (Grundy & Sloggett, 2003; Zunzunegui, Beland, & Otero, 2001). Although only a few studies focusing on the influence of social support on the mental health of older adults have been carried out in Spain, they show a clear association between both variables (Lahuerta, Borrell, Rodríguez-Sanz, Pérez, & Nebot, 2004; Rueda & Artazcoz, 2009). Moreover, Spain shows one of the highest correlations between social support and mental health among the general population, with people perceived as receiving higher levels of social support being those with better mental health outcomes (Ministry of Health and Consumer Affairs, 2007).
The aim of this study was to analyze health inequalities among older adults in Spain by adopting a conceptual framework that globally considers two dimensions of health determinants (the socioeconomic development of the region of residence and gender) and the mediating influence of social support, taking into account individual socioeconomic position. To do that, four regions were selected as representative of the two extreme cases: The Basque Country and Navarra as the two socioeconomically developed regions and Andalusia and the Region of Murcia as the two less socioeconomically developed ones. For instance, whereas illiterate people in 2009 constituted 3.79% and 4.01% of the population in the Basque Country and Navarra, respectively, the data for Murcia and Andalusia were 16% and 15.84%, respectively. In the same period, the gross domestic product per capita in the Basque Country and Navarra represented 30,662.22 Euros and 29,475.17 Euros, whereas in Andalusia and in the Region of Murcia was 17,486.67 Euros and 18,718.76 Euros, respectively (National Statistics Institute, 2010).
Four research questions lay behind this model. 1) Is the self-rated health status of older adults living in the Basque Country and Navarra better than that of older adults living in Andalusia and in the Region of Murcia, as found among the general population? 2) Does the psychological dimension of health follow the same pattern? 3) Is the relationship of social support with both indicators of health status similar in the four regions? 4) Are gender inequalities larger in the less socioeconomically developed regions (Andalusia and the Region of Murcia) than in the more developed ones (the Basque Country and Navarra)?
Based on the theoretical considerations and previous findings, four hypotheses were formulated to be tested in this analysis. 1) Self-rated health status of older adults living in the two more socioeconomically developed regions is better than that of older adults living in the less developed ones. 2) Mental health status of older adults living in the two more socioeconomically developed regions is also better than that of older adults living in the less developed ones. 3) Social support is positively associated with the health of older adults living in the four regions, but especially regarding mental health status. 4) Gender inequalities in health are larger in the two less socioeconomically developed regions than in the two more developed ones.
Section snippets
Data
Data came from the 2006 Spanish National Health Interview Survey, a cross-sectional study representative of the noninstitutionalized population of Spain. For the purposes of this study a subsample of people aged 65 to 85 years who had no paid job living in four regions with differences in socioeconomic development was selected: The Basque Country (102 men and 143 women), Navarra (128 men and 265 women), Andalusia (172 men and 371 women), and the Region of Murcia (133 men and 288 women). The
General Description of the Population
Table 1 shows the general description of the population under study. Women had lower educational attainments than men in all the regions analyzed except in Navarra. Age, type of household, and level of social support (both confidant and affective), however, were similar for both gender in all four regions except for the level of affective social support in the Basque Country, which was lower for men in this region. Regarding health indicators, women were more likely to report poor self-rated
Discussion
This is the first study analyzing health inequalities among older adults in Spain by adopting a conceptual framework that globally considers two dimensions of health determinants (gender and the socioeconomic development of the region of residence) and the mediating influence of social support, taking into account individual socioeconomic position.
The higher prevalence of poor self-rated health status among people living in less socioeconomically developed regions in Spain has been reported in
Acknowledgments
The authors thank to Lucía Artazcoz for her valuable comments and suggestions.
Silvia Rueda has a PhD in Social and Political Sciences and a master’s degree in Public and Social Policies. She leads the health area of the DEP Institute, a sociological research center. Her areas of research expertise include health inequalities, health policies and evaluation of public policies.
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Silvia Rueda has a PhD in Social and Political Sciences and a master’s degree in Public and Social Policies. She leads the health area of the DEP Institute, a sociological research center. Her areas of research expertise include health inequalities, health policies and evaluation of public policies.
Partially funded by CIBER Epidemiología and Salud Pública and by the Ministerio de Sanidad y Consumo - Observatorio de Salud de la Mujer, Dirección General de la Agencia de Calidad - y Ministerio de Ciencia e Innovación - Instituto de Salud Carlos III.