Population Research and Policy Review

, Volume 31, Issue 1, pp 97–117 | Cite as

Socioeconomic Inequalities and Self-Rated Health: A Multilevel Study of Italian Elderly



We adopted a multilevel approach in order to provide a comprehensive overview of the main social and economic differences associated with inequalities in self-rated health, according to the territorial context of residence. We focused on the Italian population aged 65 and over, availing of the most recent data on health conditions in Italy. This study proves the persistence in Italy, a modern welfare state that has one of the best overall healthcare systems in the world, of significant, if not enormous, socioeconomic differences in self-perceived health among the elderly. We found that each component of the socioeconomic status is autonomously correlated with individual perceptions of health, highlighting the importance of considering all of the facets of the individual socioeconomic status in measuring the extent of health inequalities. The lack of a network of relationships was also found to be strongly associated with a poor health status for elderly Italians. Our study also documented the presence of a contextual effect. The proposed multilevel modeling proved to be useful in shedding light on relevant aspects in the field of perceived health and for avoiding misleading results.


Self-rated health Elderly Socioeconomic inequalities Multilevel approach Relationship networks 


  1. Avlund, K., Holstein, B. E., Osler, M., Damsgaard, M. T., Holm-Pedersen, P., & Rasmussen, N. K. (2003). Social position and health in old age: The relevance of different indicators of social position. Scandinavian Journal of Public Health, 31(2), 126–136.CrossRefGoogle Scholar
  2. Blalock, H. M. (1984). Contextual-effects models: Theoretical and methodological issues. Annual Review of Sociology, 10, 353–372.CrossRefGoogle Scholar
  3. Blane, D., Davey Smith, G., & Bartley, M. (1993). Social selection: What does it contribute to social class differences in health? Sociology of Health & Illness, 15, 1–15.CrossRefGoogle Scholar
  4. Borg, V., & Kristensen, T. S. (2000). Social class and self-rated health: Can the gradient be explained by differences in life style or work environment? Social Science and Medicine, 51, 1019–1030.CrossRefGoogle Scholar
  5. Bryk, A. S., & Raudenbush, S. W. (1992). Hierarchical linear models. Newbury Park, CA: Sage.Google Scholar
  6. Carle, A. C. (2009). Fitting multilevel models in complex survey data with design weights: Recommendations. BMC Medical Research Methodology, 9, 49.CrossRefGoogle Scholar
  7. Carrieri, V. (2008), Disuguaglianze di salute e condizioni socioeconomiche in Italia: Esiste una questione meridionale? Politiche sanitarie, n.1.Google Scholar
  8. Cavelaars, A. E. J. M., Kunst, A. E., Geurts, J. J. M., et al. (1998). Differences in self-reported morbidity by educational level: A comparison of 11 Western European countries. Journal of Epidemiology Community Health, 52, 219–227.CrossRefGoogle Scholar
  9. Costa, G., Marinacci, C., Caiazzo, A., & Spadea, T. (2003). Individual and contextual determinants of inequalities in health: The Italian case. International Journal of Health Services, 33, 635–667.CrossRefGoogle Scholar
  10. Costa-Font, J. (2008). Housing assets and the socio-economic determinants of health and disability in old age. Health and Place, 14(3), 478–491.CrossRefGoogle Scholar
  11. Demakokos, P., Nazroo, J., Breeze, E., & Marmot, M. (2008). Socioeconomic status and health: The role of subjective social status. Social Science and Medicine, 67(2), 330–340.CrossRefGoogle Scholar
  12. Egidi, V., & Spizzichino, D. (2006). Perceived health and mortality: A multidimensional analysis of ECHP Italian Data. Genus, LXII(3–4), 135–154.Google Scholar
  13. Egidi, V., & Spizzichino, D. (2007). Dimensioni oggettive e soggettive delle differenze di genere nella salute. In A. Pinnelli, F. Racioppi, & L. Terzera (Eds.), Genere, Famiglia e Salute. Milan, Italy: Franco Angeli Editore.Google Scholar
  14. France, G., Taroni, F., & Donatini, A. (2005). The Italian health-care system. Health Economy, 14, 187–202.CrossRefGoogle Scholar
  15. Giarelli, G. (2009). Modelli esplicativi delle disuguaglianze di salute: una riflessione sociologica. In G. Costa, C. Cislaghi, & N. Caranci (a cura di). (2009). Le disuguaglianze sociali di salute, Problemi di definizione e di misura, Salute e Società (Vol. 1, pp. 58–78). Franco Angeli Editore, Italy.Google Scholar
  16. Grilli, L., & Pratesi, M. (2004). Weighted estimation in multilevel ordinal and binary models in the presence of informative sampling designs. Survey Methodology, 30, 93–103.Google Scholar
  17. Grundy, E., & Holt, G. (2001). The socioeconomic status of older adults: How should we measure it in studies of health inequalities? Journal of Epidemiology Community Health, 55, 895–904.CrossRefGoogle Scholar
  18. Grundy, E., & Slogget, A. (2003). Health inequalities in the older population: The role of personal capital, social resources and socio-economic circumstances. Social Science and Medicine, 56, 935–947.CrossRefGoogle Scholar
  19. Huisman, M., Kunst, A. E., & Mackenbach, J. P. (2003). Socioeconomic inequalities in morbidity among the elderly; a European overview. Social Science and Medicine, 57, 861–873.CrossRefGoogle Scholar
  20. Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38(1), 21–37.CrossRefGoogle Scholar
  21. ISTAT. (2004). Indagine sui Presidi residenziali socio-assistenziali, Anno 2004.Google Scholar
  22. ISTAT. (2007a). Condizioni di salute, fattori di rischio e ricorso ai servizi sanitari. Anno 2005, Statistiche in breve, Roma.Google Scholar
  23. ISTAT. (2007b). Nota metodologica dell’Indagine “Condizioni di salute, fattori di rischio e ricorso ai servizi sanitari”—Anno 2005, Statistiche in breve, Roma.Google Scholar
  24. Kunst, A. E., Bos, V., Lahelma, E., et al. (2005). Trends in socioeconomic inequalities in self-assessed health in 10 European countries. International Journal of Epidemiology, 34(2), 295–305.CrossRefGoogle Scholar
  25. Mackenbach, J. P., Stirbu, I., Roskam, A. R., et al. (2008). Socioeconomic inequalities in health in 22 European countries. The New England Journal of Medicine, 358, 2468–2481.CrossRefGoogle Scholar
  26. Martins, J. O., De la Maisonneuve, C., & Bjornerud, S. (2006). Projections of OECD health and long-term care public expenditures. In Proceedings of the Public Finance Workshop, Perugia, 30 March–1 April 2006, Research Department Banca d’Italia.Google Scholar
  27. Mazzuco, S. (2009). Condizioni di salute nelle regioni italiane. In F. Ongaro & S. Salvini (Eds.), Rapporto sulla Popolazione—Salute e Sopravvivenza. Il Mulino, Bologna: Gruppo di Coordinamento per la demografia.Google Scholar
  28. McNiece, R., & Majeed, A. (1999). Socioeconomic differences in general practice consultation rates in patients aged 65 and over: Prospective cohort study. British Medical Journal, 319, 26.CrossRefGoogle Scholar
  29. Molarius, A., Berglund, K., Eriksson, C., Lambe, M., Bordstrom, E., Eriksson, H. G., et al. (2006). Socioeconomic conditions, lifestyle factors, and self-rated health among men and women in Sweden. European Journal of Public Health, 17(2), 125–133.CrossRefGoogle Scholar
  30. Olsen, K. M., & Dahl, S. (2007). Health differences between European Countries. Social Science and Medicine, 64, 1665–1678.CrossRefGoogle Scholar
  31. Ongaro, F., & Salvini, S. (2009). Socio-economic conditions and health inequalities in Italy at the beginning of the XXI century. Paper presented at the XLVI Scientific Meeting Sieds, Florence, 28–30 May 2009.Google Scholar
  32. Pirani, E., & Salvini, S. (2010). Socioeconomic and territorial inequalities in health: findings for Italian elderly, Working Paper 2010/05, Department of Statistics “G. Parenti”, Firenze University Press. http://www.ds.unifi.it/ricerca/pubblicazioni/working_papers/2010/wp2010_05.pdf.
  33. Pirani, E., & Salvini, S. (2011). Investigating socioeconomic differences in health services use: A latent class model for Italian regions. Paper presented at the Giornate di Studio sulla Popolazione, Ancona, 1–4 Feb 2011.Google Scholar
  34. Prati, S., & Frova, L. (2011). Sopravvivenza e salute. In S. Salvini & A. De Rose (Eds.), Rapporto sulla Popolazione—L’Italia a 150 anni dall’Unità. Il Mulino, Bologna: Associazione Italiana per gli Studi di Popolazione.Google Scholar
  35. Rabe-Hesketh, S., & Skrondal, A. (2006). Multilevel modeling of complex survey data. Journal of the Royal Statistical Society Series A—Statistics in Society, 169, 805–827.CrossRefGoogle Scholar
  36. Rabe-Hesketh, S., & Skrondal, A. (2008). Multilevel and longitudinal modeling using Stata (2nd ed.). College Station, TX: Stata Press.Google Scholar
  37. Rueda, S., Artazcoz, L., & Navarro, V. (2008). Health inequalities among the elderly in Western Europe. Journal of Epidemiology Community Health, 62, 492–498.CrossRefGoogle Scholar
  38. United Nations. (2009). World population ageing 2009. Department of Economic and Social Affairs, Population Division, ESA/P/WP/212.Google Scholar
  39. Vignoli, D., & De Santis, G. (2009). Individual and contextual correlates of economic difficulties in old age in Europe. Population Research Policy Review, 29(4), 481–501.CrossRefGoogle Scholar
  40. Volkers, A. C., Westert, G. P., & Schellevis, F. G. (2007). Health disparities by occupation, modified by education: A cross-sectional population study. BMC Public Health, 8(7), 196.CrossRefGoogle Scholar
  41. Voller, F., & Buiatti, E. (2006). Disuguaglianze e stili di vita in Italia, Salute e Territorio, 158.Google Scholar
  42. Von dem Knesebeck, O., Luschen, G., Cockerham, W. C., & Siegrist, J. (2003). Socioeconomic status and health among the aged in the United States and Germany: A comparative cross-sectional study. Social Science and Medicine, 57, 1643–1652.CrossRefGoogle Scholar
  43. Von dem Knesebeck, O., Verde, P. E., & Dragano, N. (2006). Education and health in 22 European countries. Social Science and Medicine, 63, 1344–1351.CrossRefGoogle Scholar
  44. Yngwe, M. A., Diderichsen, F., Whitehead, M., Holland, P., & Burstrom, B. (2001). The role of income differences in explaining social inequalities in self-rated health in Sweden and Britain. Journal of Epidemiology Community Health, 55, 556–561.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  1. 1.Department of Statistics ‘‘G. Parenti’’University of FlorenceFlorenceItaly

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