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Geriatr Gerontol Int 2014; 14: 926–933
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Health status of independently living older adults in Romania Minerva Ghinescu,1 Marinela Olaroiu,1 Jitse P van Dijk,2,3 Tatiana Olteanu4 and Wim JA van den Heuvel1,2 1
Department of Primary Health Care, Titu Maiorescu University, Bucharest, Romania; 2Department of Community & Occupational Health, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands; 3Graduate School Kosice Institute for Society and Health, Medical Faculty, Safarik University, Kosice, Slovak Republic; and 4Department of Research, Ana Aslan Institute of Gerontology, Bucharest, Romania
Aim: Aging is affecting health care all over Europe, but it is expected to have a much greater impact in Eastern Europe. Reliable data on various indicators of health of older adults in Eastern Europe are lacking. The objectives of the present study were to describe the health of older Romanian adults, and to examine its relationship with sociodemographic, psychological and social factors. Methods: This cross-sectional study used a stratified sample of 600 independent-living older Romanian adults from the great metropolitan area of Bucharest; 549 citizens aged ≥65 years participated. Data were collected by a mailed questionnaire and interviews. Measurements included self-rated health, the number of chronic conditions, the Short Form-20, the Eysenck Personality Questionnaire and Social support. Results: Romanian older adults rate their health as “fair”. On average, they report three chronic conditions. They more frequently have problems in executing daily activities as compared with older adults from other European countries. Three components of health are identified: independent functioning, suffering from chronic diseases and psychological health. Regression analysis shows that age, education and social support are related to each component, and neuroticism and extraversion to two components of health. Conclusions: A comparison with international data shows various indicators of health of older Romanian adults to be relatively worse. The three identified components of health offer opportunities for an integrated approach to deal with the health care needs of older citizens. Geriatr Gerontol Int 2014; 14: 926–933. Keywords: activities of daily living, health status, neuroticism, psychological health, social support.
Introduction The growing number of dependent older adults in Europe will place new demands on the health services in European countries.1–3 However, large differences exist within Europe. Aging is developing faster in former communist Central–East European (CEE) countries as compared with Western European countries, whereas their total population decreases and long-term care arrangements are lacking.1,4 In the coming decades, the number of people aged 65 years and older will increase Accepted for publication 17 October 2013. Correspondence: Professor Wim J A van den Heuvel PhD, UMCG, University of Groningen, Heggerweg 2a, 6176RB Spaubeek, the Netherlands. Email: [email protected]
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doi: 10.1111/ggi.12199
by 5.4% in Romania, whereas at the same time the total population will decrease by 3.1%. The same demographic shifts are found in countries like Bulgaria (5.8%, respectively 5.7%), Hungary (5.4%, respectively 1.9%) and Poland (9.4%, respectively 1.5%).2 These CEE countries were characterized by dramatic socioeconomic changes in the 1990s, which led to negative changes in the health status of the population.5,6 Bulgaria, Hungary and Romania had the highest agestandardized death rates of treatable mortality in the European Union in 1990/1991, and this was still the case in 2000/2002 for Bulgaria and Romania.5 Preventable mortality for both men and women has increased in recent decades in Romania, the only country in the EU where these rates have shown an increase. The mortality of the elderly improved only marginally in Bulgaria and Romania between 1996 and 2006.5 Furthermore, the © 2013 Japan Geriatrics Society
Health status of older adults in Romania
ability of the elderly to adapt to the changing conditions was limited, and they usually waited passively for services.7 In contrast, family ties continue to be an important form of emotional and instrumental support between children and aged parents.8 Reliable and detailed data on the health status of the older adults in Eastern Europe are largely lacking, whereas instruments to assess the health status of old citizens in a comprehensive way are seldom applied. Such data are required to maintain the present health care services, to evaluate these and to plan new ones.3,9 Data available on the health status of the population in CEE countries are based on single measures, such as mortality, life expectancy or specific causes of morbidity,10,11 but such measures might not contain all dimensions of health, nor do they necessarily show the (health care) needs of older citizens. Some researchers view self-rated health as an interesting and promising indicator to assess health in older adults.12,13 Others prefer data on functional abilities or chronic diseases. However, as the World Health Organization definition on health shows, an assessment of health status should include various aspects; that is, physical, psychological and social functioning. Therefore, the present study uses various indicators to describe the health status of older adults in Romania. The relationship between various indicators of health identifies older citizens with complex health problems or at risk for dependence. A study in 11 Western European countries showed associations between subjective health, chronic diseases, depression and mobility difficulties.14–18 However, considerable differences exist in health status even within Western European countries.3 Therefore, it is necessary to analyze which factors are associated with various components of the health of older adults. The literature shows a range of relationships between sociodemographic variables, psychological and social characteristics of older adults, and various indicators of health.3,17–26 Older age and being female are associated with more health problems and negative subjective health,22,23 but this was not found among the advanced old.3 Low level of education, low income and living alone have been found to be associated with poor health status.3,22,23 Older adults seeking social engagement (high extraversion), are found to have a positive subjective health, better physical functioning and reduced risk of mortality, whereas those with poor coping with stress and experiencing situations as threatening (high neuroticism) have a negative subjective health and more medical problems.24–27 Studies also show a relationship between social support and health in middle or old age: lack of support is related to negative (mental) health.28–30 The aim of the present study was to describe the health status of older Romanian adults using various indicators, and to analyze the relationship between © 2013 Japan Geriatrics Society
health status indicators and sociodemographic, psychological, and social characteristics. These characteristics might be differently related to health indicators in CCE countries as compared with more “Western” countries, because health status is affected by the societal context in which older citizens live. In the case of elderly Romanians, it has to be understood that they have been confronted with major changes in the past 20 years. Two are especially relevant here. One regards the change in social security. The role of the public pension system was reduced in favor of private or voluntary collective schemes, causing loss of pension income and feelings of insecurity in older people.31 In addition, the pensions in Romania did not compensate fully for price increases over the decades. Poverty increased and living conditions deteriorated for elderly Romanians. The other regards health care reforms. The centralized, completely state-controlled and -owned health care system, with a central role for hospitals and offering free health care for everybody, was transformed into a health insurance system. Co-payment was introduced for most health care services, as well as a minimum package of services.32 The state budget for health care has decreased several times, and hospitals have a shortage of personnel and resources. Accessibility to health care facilities and quality of care has deteriorated in the past decade, which affects older people in particular. Health in all older Romanian adults can be expected to be affected indirectly by these changes.
Methods The data were collected in a cross-sectional study among older adults (aged 65 years and older) living in the great metropolitan area of Bucharest, Romania. The number of people aged 65 years and older was 353 349 in the six districts of the greater Bucharest area.33
Sampling A stratified sample of older adults aged 65 years and older was taken from the six districts. The sample was stratified by sex and four age groups, on the basis of national population statistics; that is, sex (41% male and 59% female) and four age groups (65–69: 37%, 70–74: 30%, 75–79: 20%, 80 years and older: 13%).33 A total of 100 older adults were selected randomly from the population register in each district. If the selected older adults agreed to participate by providing written consent, they received a mailed questionnaire, which was followed by an interview at home by trained assistants. The response rate was 91.2%; 51 persons refused the interview. The data of two respondents were incomplete. No statistically significant differences were found in sex or age | 927
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between participants and non-participants. Sex distribution conformed national Romanian data; older age groups were slightly underrepresented in the sample.
Measures The questionnaire and the interview protocol used were in English as part of an international comparative study. These were translated into Romanian and backtranslated independently. Sociodemographic data were measured in a standard manner. Age was measured by years of age, and sex by male and female. Marital status was measured by status across five categories (1 = married/living together, 2 = not married/living together, 3 = widowhood, 4 = divorced/no partner now, 5 = never had partner). Educational level was divided into eight categories (1 = unfinished elementary education, 2 = finished elementary education, 3 = lower occupational education, 4 = lower general education, 5 = middle occupational education, 6 = middle general education, 7 = high [occupational] education, 8 = university level: Master’s degree). Activities of daily living (ADL) and instrumental activities in daily living (IADL) were assessed by the Groningen Activity Restriction Scale (GARS), a wellvalidated hierarchical scale. Scores ranged from 11 to 44 for ADL (11 items) and from 7 to 28 for IADL (7 items), the highest score meaning a maximum amount of restrictions to execute (instrumental) daily activities.34 Cronbach’s alpha was 0.92 for ADL and 0.88 for IADL. Self-rated health was assessed using one question, which asked respondents to evaluate their health from poor, average, good, very good or excellent (1 to 5, respectively). Morbidity was counted by the number of chronic conditions each respondent reported having in the past 12 months using the Central Bureau of Statistics chronic conditions scale, which consists of 19 possible chronic conditions.35 The Sort Form (SF)-20, a well-validated instrument, was used to assess various aspects of functioning and health; that is, physical functioning (6 items), role performance (2 items), social functioning (1 item), psychological health (5 items), perceived health (5 items) and bodily pain (1 item). The (recoded) scores ranged from 0 to 100, with a higher score meaning fewer limitations in physical and social functioning, better psychological and perceived health, better role performance, and higher bodily pain.36–38 Perceived health includes five items; one item rates health on a five-point scale (from 1 excellent to 5 poor); other items, such as “I am as healthy as anybody I know” and “I have been feeling bad lately”, include comparative aspects of health.38 Neuroticism and extraversion were assessed using the subscales of the Eysenck Personality Questionnaire.39 Neuroticism is seen as a personality characteristic that 928 |
shows less emotional stability and increased sensitivity to stress. Extraversion shows more outgoing and communicative personality traits. The neuroticism and extraversion subscales both contain 12 items. Items were scored by respondents as yes = 1 or no = 2, and recoded as yes = 1 and no = 0, meaning a high score showed high neuroticism or high extraversion. In the present sample, Cronbach’s alpha was 0.88 for neuroticism and 0.71 for extraversion. Social support was measured with a 12-item scale asking about everyday support (4 items), support for problems (4 items) and appreciation of social support (4 items).40 Scores range from 1 = hardly any contact/ support to 4 = very much contact/support. Principal component analysis showed a one factor solution. Cronbach’s alpha was 0.91.
Analysis First, the sample data and the scores on the 10 health indicators were described. Next, the relationship between the health indicators was analyzed by factor analysis (principal component, varimax rotation). Finally, the association of socio-demographic data, psychological characteristics and social support with health status dimensions was analyzed using stepwise linear regression analysis. In the first step we introduced the sociodemographic data, in the second step the psychological characteristics neuroticism and extraversion, and in the third step we introduced social support. We presented the final models and reported the changes in statistically significant contribution per step. Tolerance for collinearity was tested. We used SPSS 20.0 (IBM SPSS Statistics, Chicago, IL, USA).
Results The sample included 58.0% women and 42.0% men; their average age was 72 years. The proportion of very old (aged 80 years and older) was 9.5%; the age group 65–69 years was the largest with 42.6% (see Table 1). Almost half of the respondents (49.5%) were married and 38.2% were widowed. Only a few respondents never had a partner or were married. The various levels of education were well represented in the sample. One out of five respondents reported an education at bachelor’s level or higher; 23.1% reported to have elementary school or less. Over half of the older Romanian adults had a score on neuroticism of 4 or lower, showing a relatively low neuroticism. A quarter of the respondents scored high (scores 10–11–12) on extraversion. Social support was received very often (score >40) by 7.9%; only one person reported hardly any contact, help or support. One out of five older Romanian citizens reported that they required no help in daily activities, meaning they © 2013 Japan Geriatrics Society
Health status of older adults in Romania
Table 1 Sociodemographic characteristics, personal characteristics, social support and 10 indicators of health status of 547 older Romanian adults Variables Sex Male Female Age 65–69 years 70–74 years 75–79 years 80 years and older Marital status Married/living together Not married/living together Widowhood Divorced/no partner now Never had partner Level of education (range 1–8) Neuroticism (range 0–12) Extraversion (range 0–12) Social support (range 12–36) Activities of daily living (range 11–44) Instrumental activities of daily living (range 7–28) Self rated health (range 1–5) Number of chronic conditions (range 0–19) Physical functioning (range 0–100) Psychological functioning (range 0–100) Perceived health (range 0–100) Role functioning (range 0–100) Social functioning (range 0–100) Bodily pain (range 0–100)
were completely independent in executing ADL; 3.3% reported that they required help with almost all activities, such as dressing, washing and using the toilet. Help with almost all instrumental daily activities, such as shopping or cleaning the house, was required by 6.7%, but 22.0% of the respondents were completely independent in IADL. Older Romanian adults rated their own health as fair on average when asked to rate their health from poor to excellent; one quarter rated it as poor, and 4.0% as very good or excellent. Three chronic conditions were reported on average; 2.4% reported not having a chronic disease condition, and 15.6% reported having one chronic condition, whereas 20.0% reported more than four. The five aspects of the SF-20 had a score between 50–60, with the exception of perceived health. A total of 80 (14.6%) older Romanian adults in the study reported excellent physical functioning. Nobody had an excellent score on psychological functioning, but 8.1% scored between 80 and 84. Perceived health scores © 2013 Japan Geriatrics Society
Percentage (n)
Mean average
Standard deviation
42.0% (230) 58.0% (317) 42.6% (233) 31.1% (170) 16.8% (92) 9.5% (52)
71.64
5.33
4.29 4.44 6.33 30.54 15.46 13.46 2.12 3.19 59.03 57.15 31.17 59.91 58.09 56.76
1.96 3.60 4.12 7.61 4.92 5.13 0.82 1.89 30.90 15.40 18.88 42.32 26.86 27.73
49.5% (271) 1.1% (6) 38.2% (209) 9.0% (49) 2.2% (12)
were rather low, with 11.0% of the older adults scoring 50 or higher. Almost half reported excellent role functioning as well as social functioning; that is, they could carry out necessary roles and social activities more or less without problems. Approximately one out of 10 older adults reported a maximum score on pain; the same proportion reported no pain at all. Next the relationship between the 10 health indicators was analyzed. Correlations between the indicators were all significant at the P < 0.001 level. Principal component analysis, using eigenvalue >1.0 as the criterion, resulted in a two-factor solution. However, the two components did not show a consistent pattern. If one factor solution was chosen, the contribution of some indicators became rather low (communality 0.90) explaining 69.6% of the variance (see Table 2). Three components of health were identified. Factor 1 assessed independent functioning in (instrumental) | 929
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Table 2 Factor analysis (principal components; three factor solution, varimax rotation) of 10 health indicators, factor loadings and communalities Health status indicator
Factor 1 Factor 2 Factor 3 Communality
Activities of daily living Instrumental activities of daily living Self-rated health Number of chronic conditions Physical functioning (SF-20) Psychological health (SF-20) Perceived health (SF-20) Role functioning (SF-20) Social functioning (SF-20) Bodily pain (SF-20) Explained variance
−0.898 −0.854
−0.160 −0.231
−0.032 −0.074
0.833 0.788
0.292 −0.145 0.597 0.013 0.275 0.552 0.572 −0.175 27.36
0.653 −0.793 0.406 0.166 0.708 0.264 0.124 −0.698 23.98
0.462 0.093 0.302 0.830 0.370 0.491 0.601 −0.275 18.22
0.725 0.658 0.613 0.716 0.713 0.616 0.703 0.593 69.56
SF-20, Short Form 20.
Table 3 Final models after stepwise linear regression analysis, standardized beta coefficients, level of statistical significance, adjusted R2 and dependent variables: independent functioning, suffering from chronic diseases and psychological health Independent variables
Independent functioning
Suffering from chronic diseases
Psychological health
Sex Age Marital status Education Neuroticism Extraversion Social support Total explained variance (adjusted R square)
0.063 −0.321** −0.002 0.095* −0.053 0.136** −0.134** 14.1%
−0.130** 0.101* −0.007 0.104* −0.101* −0.043 −0.133** 6.4%
−0.017 −0.082* −0.004 0.120** −0.331** 0.096* 0.177** 25.5%
Standardized Beta coefficients are presented. *Statistically significant at P < 0.05 level. **Statistically significant at P < 0.01 level.
daily activities required to live independently. ADL and IADL showed the highest factor loadings (>0.85). This factor was supported by role functioning and social functioning, and explained after varimax rotation 27.4% of the variance. Factor 2 assessed suffering from chronic diseases; that is, various chronic health problems, suffering from pain and perceiving health as poor. This factor explained 24.0%, and showed chronic conditions, related with pain, as well as perceived health (also in comparison with others) with the highest factor loadings (>0.69). Factor 3 dealt with psychological health, explaining 18.2%, showing that old citizens who feel psychologically well also are socially active. Factor scores per respondent on each component were calculated. The independent variables were introduced stepwise in the regression analysis; that is, sociodemographic variables, psychological characteristics and social support. The final model for each component is pre930 |
sented in Table 3. Each step contributed was statistically significant. The total explained variance of the final model varied between 6.4% for “suffering from chronic diseases” and 25.5% for “psychological health”. Age, education, extraversion and social support contributed statistically significantly to the factor independent functioning. Age and education contributed statistically significantly in the first step. Extraversion contributed statistically significantly in the third step after social support was introduced. The total explained variance was 14.1%. Older Romanian adults of advanced age, with a lower education, being less extravert and receiving less social support more often had problems with independent functioning. Sex, age and education were statistically significantly related to suffering from chronic diseases in the first step of the regression analysis and kept their contribution during the next two steps. In step 2, neuroticism and extraversion both contributed statistically © 2013 Japan Geriatrics Society
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significantly, but the contribution of extraversion dropped significantly after social support was introduced in step 3. Women, citizens of younger age, with a lower education, high neuroticism and receiving frequent social support reported more suffering from chronic diseases. The total explained variance was 6.4%. Neuroticism, social support, education, extraversion and age were related to “psychological health”. Age contributed statistically significantly in the third step after social support was introduced. The total explained variance was 25.5%. Older Romanian adults with a good psychological health were characterized by younger age, high education, low neuroticism, high extraversion and frequent social support.
Discussion One objective of the present study was to describe the health status of older, independent living Romanian adults. The findings showed that the average health status of older Romanian adults is far from good. Examining individual health indicators, we can compare these with some data from other countries. As part of an international project, the same data were collected in a large city in Poland and in three cities in Croatia, using the same methodology in sampling and data collection. Older Romanian adults report worse psychological health (mean score 57.2) and social functioning (mean score 58.1) as compared with older adults from Poland (65.2 respectively 89.7) and Croatia (61.1 respectively 78.2).41 Older Romanian adults have more problems in executing (instrumental) daily activities (mean score ADL 15.5 and IADL 13.5) as compared with Polish (13.5 respectively 10.7) and Croatian (13.9 respectively 10.3) older adults.41 These findings about the worse health status of older Romanian adults underline the findings about avoidable mortality and slow increase of life expectancy.4,9 A comparison with a Dutch sample of older adults in the northern part of the Netherlands shows that in Dutch older adults the psychological health (mean score 76.0) is again much higher than in Polish and Croatian older adults.42 Also, Dutch older adults score higher on physical functioning, perceived health and role functioning as compared with Romanian, Polish and Croatian older adults.42 Another comparative European study showed physical and mental health of Dutch old comparable with those from Belgium, France, Germany, Italy and Spain.3 These outcomes do show a clear difference in health status between older adults from “Western” European countries as compared with older adults from “Eastern” European countries. Older Romanian adults in particular have problems in carrying out daily activities, in social functioning, and psychological health. © 2013 Japan Geriatrics Society
Three components of health were identified; that is, independent functioning, suffering from chronic diseases and psychological health. We believe it is important to distinguish between these components of health in Romanian older adults because they are partly independent from each other and have their “own” relationship with independent factors. Developing chronic diseases when aging is related to pain and low self-rated health. Worse psychological health is related to worse social functioning, but not to dependence in (instrumental) daily activities. By assessing health status in this way, interventions could be directed to the specific health care problems older Romanian adults experience. Various independent variables are related to the different health components. Age, education and social support were statistically significantly related to all these health components, but not in the same way necessarily. Higher education might allow older citizens to create more possibilities for coping with the poor economic and limiting infrastructure. Social support; that is, family support, still is a strong tradition in Romania. This social support to older adults by family and neighbors matters. Not receiving social support affects the possibilities of independent daily activities directly and negatively. However, social support is given as the regression analysis on independent functioning shows: very old Romanians are more dependent, but they also receive more social support. In an Eastern European study, a considerable level of emotional support was found between adult children and their elderly parents; this support did continue in difficult times.8 Besides the crucial role of education and social support, neuroticism and extraversion related to the health of older Romanian adults. The relationship between neuroticism and extraversion, and health components is in line with other studies, which show that neuroticism is associated with more reported medical (chronic) problems and is negatively related to psychological health.25,43 Marital status was not related to health components, whereas sex was only related to suffering from chronic conditions. In a Polish study, a strong relationship was found between socioeconomic status and self-rated health.22 A Dutch study showed an important role of marital status and income in deterioration of functioning among older adults.44 More longitudinal research is required to understand the role of various independent variables on health components when people are aging. The three components show that health is more than the absence of diseases. Our data show that besides the “chronic disease” component, there is a psychological and a social component. This finding supports the discussion about whether health should be considered as a state or as an ability.45 The present findings show that health status is an ability; that is, an interaction between | 931
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chronic diseases, functional activities and psychological health determined by the social and physical environment older adults live in. Health status does differ individually and collectively in different cultures and health care systems. Therefore, it is important to have reliable data to assess the health status of citizens in each country, and to evaluate the health care system.3 Our data support the importance of assessing the health care needs of older adults in various domains of life.20,46 Data on various aspects of health in older adults living in CEE countries are scarce. The present study presented such data for Romania. We consider the study to be representative of older Romanian citizens because we used a stratified sample based on national population statistics; that is, with regard to sex and age, the present sample represents all older Romanian adults. We achieved a high response rate (91.2%), and did not find significant sex or age differences between responders and non-responders; this strengthens the representativeness of the sample. A high response rate is not unusual for surveys in CEE countries.47,48 Limitations of the present study included the crosssectional design and sampling from one metropolitan area. Longitudinal studies are required to understand the development of health in older age, and the relationship between (changes in) health and development in psychological and social factors. Such studies are scarce. Because this sample was taken from the greater metropolitan area of Bucharest, the infrastructure in which the respondents live differs from that of older adults not living in big cities. However, for all Romanian older adults, accessibility to (health care) services is difficult because of the co-payment, waiting lists and shortage of personnel/equipment, whereas their retirement income is low, as was discussed in the Introduction. Therefore, we believe the findings of the present study are representative for older Romanian adults. Also, we can compare these data with a few studies from other CEE countries, because we used the same design and methods. The present study is unique in the Romanian context. The survey covered various health aspects using internationally validated measures. Such a survey, with validated instruments and trained interviewers, is not common in CEE countries. Further research in this field is strongly recommended. As mentioned, such research should follow a longitudinal design. Also, further theoretical explorations and testing are required. Given the continuous emotional support of adult children, it could be very interesting to test findings of other studies in the Romanian context.8,30 Also, the role of social conditions on the development of health needs further research. For such international, comparative research using the same design and the same set of validated instruments, it is recommended that those countries with significantly different “social 932 |
conditions” be selected. Much European research in this field is limited to “Western” welfare states. The three health components could be used in primary health care to comprehensively assess the health care needs of elderly citizens. Such an assessment opens up a variety of ways for interventions within the existing Romanian health care system to prevent further deterioration in health and frailty.49 Given the important role of social support in relation to health care needs, a policy to maintain social (familial) networks is strongly recommended. The data are of utmost importance for Romanian policy makers. The comparison with data from other European countries shows that older Romanian adults will benefit from improvements in accessibility to health care and in the quality of health care services. Policy makers should give priority to such improvements in the health care system. Actually, health care policy is largely absent in Romanian policy.
Disclosure statement The authors declare no conflict of interest.
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Health status of older adults in Romania 12 Ford J, Spallek M, Dobson A. Self-rated health and healthy life style are the most important predictors of survival in elderly women. Age Ageing 2008; 37: 194–200. 13 Hubley AM, Russell LB. Prediction of subjective age, desired age, and age satisfaction in older adults: do some health dimensions contribute more than others? Int J Behav Dev 2009; 33: 12–21. 14 Verropolou G. Key elements composing self-rated health in older adults: a comparative study of 11 European countries. Eur J Ageing 2009; 6: 213–226. 15 Bardage C, Pluijm SMF, Pedersen NL, Deeg DJH, Jylhä M et al. Self-rated health among older adults: a cross-national comparison. Eur J Ageing 2005; 2: 149–158. 16 Gunzelmann T, Hinz A, Brähler E. Subjective health in older people. Psychosoc Med 2006; 3: 1–10. 17 Rozzini R, Frisoni GB, Bianchetti A, Zanetti O. Physical performance test and activities of daily living scales in the assessment of health in elderly people. J Am Geriatr Soc 1993; 41: 1109–1113. 18 Gurina NA, Frolova EV, Degryse JM. A roadmap of aging in Russia: the prevalence of frailty in community-dwelling older adults in the St. Petersburg district – The “Crystal” Study. J Am Geriatr Soc 2011; 59: 980–988. 19 Hall JA, Epstein AM, McNeil BJ. Multidimensionality in health status in the elderly population: construct validity of a measurement battery. Med Care 1989; 27: S168–S177. 20 Gupta I. Health in de elderly in India: a multivariate analysis. J Health Popul Dev Ctries 2003; [Cited 3 Dec 2012] Available from URL: http://www.jhpdc.unc.edu/. 21 Stineman MG, Xie D, Pan Q, Kurichi JE, Saliba D, Streim J. Activity of Daily Living staging, chronic health conditions and perceived lack of home accessibility features for elderly people living in the community. J Am Geriatr Soc 2011; 59: 454–462. 22 Knurowski T, van Dijk JP, Madarasova Geckova A, Brzyski P, Tobiasz Adamczyk B, van den Heuvel WJA. Socio-economic health differences among the elderly population in Krakow, Poland. Soz Praventivmed 2005; 50: 177–185. 23 Schöllgen I, Huxhold O, Tesch-Römer C. Socioeconomic status and health in the second half of life: findings from the German Ageing Survey. Eur J Ageing 2010; 7: 17–28. 24 Jerram KL, Coleman PG. The big five personality traits and reporting of health problems and health behaviour in old age. Br J Health Psychol 1999; 4: 181–192. 25 Friedman HS, Kern ML, Reynolds CA. Personality and health, subjective well-being, and longevity. J Pers 2010; 78: 179–216. 26 Wilson RS, Krueger KR, Gu L, Bienias JL, Mendes de Leon CF, Evans DA. Neuroticism, extraversion, and mortality in a defined population of older persons. Psychosomatics 2005; 67: 841–845. 27 Kempen GIJM, Jelicic M, Ormel J. Personality, chronic medical morbidity and health related quality of life among older persons. Health Psychol 1997; 16: 539–546. 28 Schaefer C, Coyne JC, Lazarus RS. The healthrelated functions of social support. J Behav Med 1982; 4: 381–406. 29 Wenger GC, Davies R, Shahtahmasebi S, Scott A. Social isolation and loneliness in old age: review and model refinement. Ageing Soc 1996; 16: 333–358.
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30 Cornwell EY, Waite LJ. Social disconnectedness, perceived isolation and health among older adults. J Health Soc Behav 2009; 50: 31–48. 31 Stanovnik T. Retirement incomes and economic wellbeing in Central and Eastern Europe. Report Conference Warsaw. CCNM/DEELSA(2002)5/FINAL. OECD; 2002. 32 Vla˘descu C, Scîntee G, Olsavszky V, Allin S, Mladovsky P. Romania: health system review. Health Systems in Transition, WHO;2008. 33 Institute National de Statistica. Recensamantul populatiei 2002, Bucharest, Romania; 2003. 34 Kempen GI, Suurmeijer TP. The development of a hierarchical polychotomous ADL-IADL scale for non institutionalized elders. Gerontologist 1990; 30: 497–502. 35 Central Bureau of Statistics. Long Lasting Health Problems in the Population. In Dutch. Voorburg/Heerlen: Vademecum Gezondheidsstatistiek, 1994. 36 Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health survey. Reliability and validity in a patient population. Med Care 1988; 26: 724–735. 37 McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires. NewYork, 2nd edn. Oxford: Oxford University Press, 1996. 38 Kempen GIJM, Brilman EI, Heying JW, Ormel J. MOS Short-Form General Health Survey (SF-20). Groningen: NCG, RijksUniversiteit van Groningen, 1995. 39 Eysenck SBG, Eysenck HJ, Barrett P. A revised version of the psychotism scale. Pers Individ Dif 1985; 6: 21–29. 40 Eijk LM, Kempen GIJK, Sonderen FLP. van. A short scale to measure social support in the elderly: the SSL12. In Dutch. Tijdschr Gerontol Geriatr 1994; 25: 192–196. 41 Knurowski T, Lazic D, van Dijk JP, Madarasova Geckova A, Tobiasz Adamczyk B, van den Heuvel WJA. Survey of health status and quality of life in the elderly in Poland and Croatia. Croat Med J 2004; 45: 750–756. 42 Kempen GIJM, Brilman EJ, Ormel J. Groningen Longitudinal Aging Study. Groningen: NCG, RijksUniversiteit van Groningen, 1995. 43 Jerram KL, Coleman PG. The big five personality traits and reporting of health problems and health behaviour in old age. Br J Health Psych 1999; 4: 181–192. 44 Jonker AGC, Comijs HC, Knipscheer CPM, Deeg DJH. Persistent Deterioration of Functioning (PDF) and change in in older persons. Ageing Clin Exp Res 2008; 20: 461–468. 45 Huber M, Knottnerus JA, Green L et al. How should we define health? BMJ 2011; 343: d4163. doi: 10.1136/ bmj.d4163 46 Seidel D, Brayne C, Jagger C. Limitations in physical functioning among older people as a predictor of subsequent disability in instrumental activities of daily living. Age ageing 2011; 40: 463–469. 47 Nagyova I. Self-rated health and quality of life in Slovak rheumatoid arthritis patients. Dissertation University of Groningen, the Netherlands, 2005. 48 Bara C. The Romanian health care system in transition from the users’ perspective. Dissertation University of Groningen, the Netherlands, 2003. 49 Danon-Hersch N, Rodondi N, Spagnoli J, SantosEggimann B. Prefrailty and chronic morbidity in the youngest old: an insight from the Lausanne cohort Lc65+. J Am Geriatr Soc 2012; 60: 1687–1694.
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Geriatr Gerontol Int 2014; 14: 926–933
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Health status of independently living older adults in Romania Minerva Ghinescu,1 Marinela Olaroiu,1 Jitse P van Dijk,2,3 Tatiana Olteanu4 and Wim JA van den Heuvel1,2 1
Department of Primary Health Care, Titu Maiorescu University, Bucharest, Romania; 2Department of Community & Occupational Health, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands; 3Graduate School Kosice Institute for Society and Health, Medical Faculty, Safarik University, Kosice, Slovak Republic; and 4Department of Research, Ana Aslan Institute of Gerontology, Bucharest, Romania
Aim: Aging is affecting health care all over Europe, but it is expected to have a much greater impact in Eastern Europe. Reliable data on various indicators of health of older adults in Eastern Europe are lacking. The objectives of the present study were to describe the health of older Romanian adults, and to examine its relationship with sociodemographic, psychological and social factors. Methods: This cross-sectional study used a stratified sample of 600 independent-living older Romanian adults from the great metropolitan area of Bucharest; 549 citizens aged ≥65 years participated. Data were collected by a mailed questionnaire and interviews. Measurements included self-rated health, the number of chronic conditions, the Short Form-20, the Eysenck Personality Questionnaire and Social support. Results: Romanian older adults rate their health as “fair”. On average, they report three chronic conditions. They more frequently have problems in executing daily activities as compared with older adults from other European countries. Three components of health are identified: independent functioning, suffering from chronic diseases and psychological health. Regression analysis shows that age, education and social support are related to each component, and neuroticism and extraversion to two components of health. Conclusions: A comparison with international data shows various indicators of health of older Romanian adults to be relatively worse. The three identified components of health offer opportunities for an integrated approach to deal with the health care needs of older citizens. Geriatr Gerontol Int 2014; 14: 926–933. Keywords: activities of daily living, health status, neuroticism, psychological health, social support.
Introduction The growing number of dependent older adults in Europe will place new demands on the health services in European countries.1–3 However, large differences exist within Europe. Aging is developing faster in former communist Central–East European (CEE) countries as compared with Western European countries, whereas their total population decreases and long-term care arrangements are lacking.1,4 In the coming decades, the number of people aged 65 years and older will increase Accepted for publication 17 October 2013. Correspondence: Professor Wim J A van den Heuvel PhD, UMCG, University of Groningen, Heggerweg 2a, 6176RB Spaubeek, the Netherlands. Email: [email protected]
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doi: 10.1111/ggi.12199
by 5.4% in Romania, whereas at the same time the total population will decrease by 3.1%. The same demographic shifts are found in countries like Bulgaria (5.8%, respectively 5.7%), Hungary (5.4%, respectively 1.9%) and Poland (9.4%, respectively 1.5%).2 These CEE countries were characterized by dramatic socioeconomic changes in the 1990s, which led to negative changes in the health status of the population.5,6 Bulgaria, Hungary and Romania had the highest agestandardized death rates of treatable mortality in the European Union in 1990/1991, and this was still the case in 2000/2002 for Bulgaria and Romania.5 Preventable mortality for both men and women has increased in recent decades in Romania, the only country in the EU where these rates have shown an increase. The mortality of the elderly improved only marginally in Bulgaria and Romania between 1996 and 2006.5 Furthermore, the © 2013 Japan Geriatrics Society
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ability of the elderly to adapt to the changing conditions was limited, and they usually waited passively for services.7 In contrast, family ties continue to be an important form of emotional and instrumental support between children and aged parents.8 Reliable and detailed data on the health status of the older adults in Eastern Europe are largely lacking, whereas instruments to assess the health status of old citizens in a comprehensive way are seldom applied. Such data are required to maintain the present health care services, to evaluate these and to plan new ones.3,9 Data available on the health status of the population in CEE countries are based on single measures, such as mortality, life expectancy or specific causes of morbidity,10,11 but such measures might not contain all dimensions of health, nor do they necessarily show the (health care) needs of older citizens. Some researchers view self-rated health as an interesting and promising indicator to assess health in older adults.12,13 Others prefer data on functional abilities or chronic diseases. However, as the World Health Organization definition on health shows, an assessment of health status should include various aspects; that is, physical, psychological and social functioning. Therefore, the present study uses various indicators to describe the health status of older adults in Romania. The relationship between various indicators of health identifies older citizens with complex health problems or at risk for dependence. A study in 11 Western European countries showed associations between subjective health, chronic diseases, depression and mobility difficulties.14–18 However, considerable differences exist in health status even within Western European countries.3 Therefore, it is necessary to analyze which factors are associated with various components of the health of older adults. The literature shows a range of relationships between sociodemographic variables, psychological and social characteristics of older adults, and various indicators of health.3,17–26 Older age and being female are associated with more health problems and negative subjective health,22,23 but this was not found among the advanced old.3 Low level of education, low income and living alone have been found to be associated with poor health status.3,22,23 Older adults seeking social engagement (high extraversion), are found to have a positive subjective health, better physical functioning and reduced risk of mortality, whereas those with poor coping with stress and experiencing situations as threatening (high neuroticism) have a negative subjective health and more medical problems.24–27 Studies also show a relationship between social support and health in middle or old age: lack of support is related to negative (mental) health.28–30 The aim of the present study was to describe the health status of older Romanian adults using various indicators, and to analyze the relationship between © 2013 Japan Geriatrics Society
health status indicators and sociodemographic, psychological, and social characteristics. These characteristics might be differently related to health indicators in CCE countries as compared with more “Western” countries, because health status is affected by the societal context in which older citizens live. In the case of elderly Romanians, it has to be understood that they have been confronted with major changes in the past 20 years. Two are especially relevant here. One regards the change in social security. The role of the public pension system was reduced in favor of private or voluntary collective schemes, causing loss of pension income and feelings of insecurity in older people.31 In addition, the pensions in Romania did not compensate fully for price increases over the decades. Poverty increased and living conditions deteriorated for elderly Romanians. The other regards health care reforms. The centralized, completely state-controlled and -owned health care system, with a central role for hospitals and offering free health care for everybody, was transformed into a health insurance system. Co-payment was introduced for most health care services, as well as a minimum package of services.32 The state budget for health care has decreased several times, and hospitals have a shortage of personnel and resources. Accessibility to health care facilities and quality of care has deteriorated in the past decade, which affects older people in particular. Health in all older Romanian adults can be expected to be affected indirectly by these changes.
Methods The data were collected in a cross-sectional study among older adults (aged 65 years and older) living in the great metropolitan area of Bucharest, Romania. The number of people aged 65 years and older was 353 349 in the six districts of the greater Bucharest area.33
Sampling A stratified sample of older adults aged 65 years and older was taken from the six districts. The sample was stratified by sex and four age groups, on the basis of national population statistics; that is, sex (41% male and 59% female) and four age groups (65–69: 37%, 70–74: 30%, 75–79: 20%, 80 years and older: 13%).33 A total of 100 older adults were selected randomly from the population register in each district. If the selected older adults agreed to participate by providing written consent, they received a mailed questionnaire, which was followed by an interview at home by trained assistants. The response rate was 91.2%; 51 persons refused the interview. The data of two respondents were incomplete. No statistically significant differences were found in sex or age | 927
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between participants and non-participants. Sex distribution conformed national Romanian data; older age groups were slightly underrepresented in the sample.
Measures The questionnaire and the interview protocol used were in English as part of an international comparative study. These were translated into Romanian and backtranslated independently. Sociodemographic data were measured in a standard manner. Age was measured by years of age, and sex by male and female. Marital status was measured by status across five categories (1 = married/living together, 2 = not married/living together, 3 = widowhood, 4 = divorced/no partner now, 5 = never had partner). Educational level was divided into eight categories (1 = unfinished elementary education, 2 = finished elementary education, 3 = lower occupational education, 4 = lower general education, 5 = middle occupational education, 6 = middle general education, 7 = high [occupational] education, 8 = university level: Master’s degree). Activities of daily living (ADL) and instrumental activities in daily living (IADL) were assessed by the Groningen Activity Restriction Scale (GARS), a wellvalidated hierarchical scale. Scores ranged from 11 to 44 for ADL (11 items) and from 7 to 28 for IADL (7 items), the highest score meaning a maximum amount of restrictions to execute (instrumental) daily activities.34 Cronbach’s alpha was 0.92 for ADL and 0.88 for IADL. Self-rated health was assessed using one question, which asked respondents to evaluate their health from poor, average, good, very good or excellent (1 to 5, respectively). Morbidity was counted by the number of chronic conditions each respondent reported having in the past 12 months using the Central Bureau of Statistics chronic conditions scale, which consists of 19 possible chronic conditions.35 The Sort Form (SF)-20, a well-validated instrument, was used to assess various aspects of functioning and health; that is, physical functioning (6 items), role performance (2 items), social functioning (1 item), psychological health (5 items), perceived health (5 items) and bodily pain (1 item). The (recoded) scores ranged from 0 to 100, with a higher score meaning fewer limitations in physical and social functioning, better psychological and perceived health, better role performance, and higher bodily pain.36–38 Perceived health includes five items; one item rates health on a five-point scale (from 1 excellent to 5 poor); other items, such as “I am as healthy as anybody I know” and “I have been feeling bad lately”, include comparative aspects of health.38 Neuroticism and extraversion were assessed using the subscales of the Eysenck Personality Questionnaire.39 Neuroticism is seen as a personality characteristic that 928 |
shows less emotional stability and increased sensitivity to stress. Extraversion shows more outgoing and communicative personality traits. The neuroticism and extraversion subscales both contain 12 items. Items were scored by respondents as yes = 1 or no = 2, and recoded as yes = 1 and no = 0, meaning a high score showed high neuroticism or high extraversion. In the present sample, Cronbach’s alpha was 0.88 for neuroticism and 0.71 for extraversion. Social support was measured with a 12-item scale asking about everyday support (4 items), support for problems (4 items) and appreciation of social support (4 items).40 Scores range from 1 = hardly any contact/ support to 4 = very much contact/support. Principal component analysis showed a one factor solution. Cronbach’s alpha was 0.91.
Analysis First, the sample data and the scores on the 10 health indicators were described. Next, the relationship between the health indicators was analyzed by factor analysis (principal component, varimax rotation). Finally, the association of socio-demographic data, psychological characteristics and social support with health status dimensions was analyzed using stepwise linear regression analysis. In the first step we introduced the sociodemographic data, in the second step the psychological characteristics neuroticism and extraversion, and in the third step we introduced social support. We presented the final models and reported the changes in statistically significant contribution per step. Tolerance for collinearity was tested. We used SPSS 20.0 (IBM SPSS Statistics, Chicago, IL, USA).
Results The sample included 58.0% women and 42.0% men; their average age was 72 years. The proportion of very old (aged 80 years and older) was 9.5%; the age group 65–69 years was the largest with 42.6% (see Table 1). Almost half of the respondents (49.5%) were married and 38.2% were widowed. Only a few respondents never had a partner or were married. The various levels of education were well represented in the sample. One out of five respondents reported an education at bachelor’s level or higher; 23.1% reported to have elementary school or less. Over half of the older Romanian adults had a score on neuroticism of 4 or lower, showing a relatively low neuroticism. A quarter of the respondents scored high (scores 10–11–12) on extraversion. Social support was received very often (score >40) by 7.9%; only one person reported hardly any contact, help or support. One out of five older Romanian citizens reported that they required no help in daily activities, meaning they © 2013 Japan Geriatrics Society
Health status of older adults in Romania
Table 1 Sociodemographic characteristics, personal characteristics, social support and 10 indicators of health status of 547 older Romanian adults Variables Sex Male Female Age 65–69 years 70–74 years 75–79 years 80 years and older Marital status Married/living together Not married/living together Widowhood Divorced/no partner now Never had partner Level of education (range 1–8) Neuroticism (range 0–12) Extraversion (range 0–12) Social support (range 12–36) Activities of daily living (range 11–44) Instrumental activities of daily living (range 7–28) Self rated health (range 1–5) Number of chronic conditions (range 0–19) Physical functioning (range 0–100) Psychological functioning (range 0–100) Perceived health (range 0–100) Role functioning (range 0–100) Social functioning (range 0–100) Bodily pain (range 0–100)
were completely independent in executing ADL; 3.3% reported that they required help with almost all activities, such as dressing, washing and using the toilet. Help with almost all instrumental daily activities, such as shopping or cleaning the house, was required by 6.7%, but 22.0% of the respondents were completely independent in IADL. Older Romanian adults rated their own health as fair on average when asked to rate their health from poor to excellent; one quarter rated it as poor, and 4.0% as very good or excellent. Three chronic conditions were reported on average; 2.4% reported not having a chronic disease condition, and 15.6% reported having one chronic condition, whereas 20.0% reported more than four. The five aspects of the SF-20 had a score between 50–60, with the exception of perceived health. A total of 80 (14.6%) older Romanian adults in the study reported excellent physical functioning. Nobody had an excellent score on psychological functioning, but 8.1% scored between 80 and 84. Perceived health scores © 2013 Japan Geriatrics Society
Percentage (n)
Mean average
Standard deviation
42.0% (230) 58.0% (317) 42.6% (233) 31.1% (170) 16.8% (92) 9.5% (52)
71.64
5.33
4.29 4.44 6.33 30.54 15.46 13.46 2.12 3.19 59.03 57.15 31.17 59.91 58.09 56.76
1.96 3.60 4.12 7.61 4.92 5.13 0.82 1.89 30.90 15.40 18.88 42.32 26.86 27.73
49.5% (271) 1.1% (6) 38.2% (209) 9.0% (49) 2.2% (12)
were rather low, with 11.0% of the older adults scoring 50 or higher. Almost half reported excellent role functioning as well as social functioning; that is, they could carry out necessary roles and social activities more or less without problems. Approximately one out of 10 older adults reported a maximum score on pain; the same proportion reported no pain at all. Next the relationship between the 10 health indicators was analyzed. Correlations between the indicators were all significant at the P < 0.001 level. Principal component analysis, using eigenvalue >1.0 as the criterion, resulted in a two-factor solution. However, the two components did not show a consistent pattern. If one factor solution was chosen, the contribution of some indicators became rather low (communality 0.90) explaining 69.6% of the variance (see Table 2). Three components of health were identified. Factor 1 assessed independent functioning in (instrumental) | 929
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Table 2 Factor analysis (principal components; three factor solution, varimax rotation) of 10 health indicators, factor loadings and communalities Health status indicator
Factor 1 Factor 2 Factor 3 Communality
Activities of daily living Instrumental activities of daily living Self-rated health Number of chronic conditions Physical functioning (SF-20) Psychological health (SF-20) Perceived health (SF-20) Role functioning (SF-20) Social functioning (SF-20) Bodily pain (SF-20) Explained variance
−0.898 −0.854
−0.160 −0.231
−0.032 −0.074
0.833 0.788
0.292 −0.145 0.597 0.013 0.275 0.552 0.572 −0.175 27.36
0.653 −0.793 0.406 0.166 0.708 0.264 0.124 −0.698 23.98
0.462 0.093 0.302 0.830 0.370 0.491 0.601 −0.275 18.22
0.725 0.658 0.613 0.716 0.713 0.616 0.703 0.593 69.56
SF-20, Short Form 20.
Table 3 Final models after stepwise linear regression analysis, standardized beta coefficients, level of statistical significance, adjusted R2 and dependent variables: independent functioning, suffering from chronic diseases and psychological health Independent variables
Independent functioning
Suffering from chronic diseases
Psychological health
Sex Age Marital status Education Neuroticism Extraversion Social support Total explained variance (adjusted R square)
0.063 −0.321** −0.002 0.095* −0.053 0.136** −0.134** 14.1%
−0.130** 0.101* −0.007 0.104* −0.101* −0.043 −0.133** 6.4%
−0.017 −0.082* −0.004 0.120** −0.331** 0.096* 0.177** 25.5%
Standardized Beta coefficients are presented. *Statistically significant at P < 0.05 level. **Statistically significant at P < 0.01 level.
daily activities required to live independently. ADL and IADL showed the highest factor loadings (>0.85). This factor was supported by role functioning and social functioning, and explained after varimax rotation 27.4% of the variance. Factor 2 assessed suffering from chronic diseases; that is, various chronic health problems, suffering from pain and perceiving health as poor. This factor explained 24.0%, and showed chronic conditions, related with pain, as well as perceived health (also in comparison with others) with the highest factor loadings (>0.69). Factor 3 dealt with psychological health, explaining 18.2%, showing that old citizens who feel psychologically well also are socially active. Factor scores per respondent on each component were calculated. The independent variables were introduced stepwise in the regression analysis; that is, sociodemographic variables, psychological characteristics and social support. The final model for each component is pre930 |
sented in Table 3. Each step contributed was statistically significant. The total explained variance of the final model varied between 6.4% for “suffering from chronic diseases” and 25.5% for “psychological health”. Age, education, extraversion and social support contributed statistically significantly to the factor independent functioning. Age and education contributed statistically significantly in the first step. Extraversion contributed statistically significantly in the third step after social support was introduced. The total explained variance was 14.1%. Older Romanian adults of advanced age, with a lower education, being less extravert and receiving less social support more often had problems with independent functioning. Sex, age and education were statistically significantly related to suffering from chronic diseases in the first step of the regression analysis and kept their contribution during the next two steps. In step 2, neuroticism and extraversion both contributed statistically © 2013 Japan Geriatrics Society
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significantly, but the contribution of extraversion dropped significantly after social support was introduced in step 3. Women, citizens of younger age, with a lower education, high neuroticism and receiving frequent social support reported more suffering from chronic diseases. The total explained variance was 6.4%. Neuroticism, social support, education, extraversion and age were related to “psychological health”. Age contributed statistically significantly in the third step after social support was introduced. The total explained variance was 25.5%. Older Romanian adults with a good psychological health were characterized by younger age, high education, low neuroticism, high extraversion and frequent social support.
Discussion One objective of the present study was to describe the health status of older, independent living Romanian adults. The findings showed that the average health status of older Romanian adults is far from good. Examining individual health indicators, we can compare these with some data from other countries. As part of an international project, the same data were collected in a large city in Poland and in three cities in Croatia, using the same methodology in sampling and data collection. Older Romanian adults report worse psychological health (mean score 57.2) and social functioning (mean score 58.1) as compared with older adults from Poland (65.2 respectively 89.7) and Croatia (61.1 respectively 78.2).41 Older Romanian adults have more problems in executing (instrumental) daily activities (mean score ADL 15.5 and IADL 13.5) as compared with Polish (13.5 respectively 10.7) and Croatian (13.9 respectively 10.3) older adults.41 These findings about the worse health status of older Romanian adults underline the findings about avoidable mortality and slow increase of life expectancy.4,9 A comparison with a Dutch sample of older adults in the northern part of the Netherlands shows that in Dutch older adults the psychological health (mean score 76.0) is again much higher than in Polish and Croatian older adults.42 Also, Dutch older adults score higher on physical functioning, perceived health and role functioning as compared with Romanian, Polish and Croatian older adults.42 Another comparative European study showed physical and mental health of Dutch old comparable with those from Belgium, France, Germany, Italy and Spain.3 These outcomes do show a clear difference in health status between older adults from “Western” European countries as compared with older adults from “Eastern” European countries. Older Romanian adults in particular have problems in carrying out daily activities, in social functioning, and psychological health. © 2013 Japan Geriatrics Society
Three components of health were identified; that is, independent functioning, suffering from chronic diseases and psychological health. We believe it is important to distinguish between these components of health in Romanian older adults because they are partly independent from each other and have their “own” relationship with independent factors. Developing chronic diseases when aging is related to pain and low self-rated health. Worse psychological health is related to worse social functioning, but not to dependence in (instrumental) daily activities. By assessing health status in this way, interventions could be directed to the specific health care problems older Romanian adults experience. Various independent variables are related to the different health components. Age, education and social support were statistically significantly related to all these health components, but not in the same way necessarily. Higher education might allow older citizens to create more possibilities for coping with the poor economic and limiting infrastructure. Social support; that is, family support, still is a strong tradition in Romania. This social support to older adults by family and neighbors matters. Not receiving social support affects the possibilities of independent daily activities directly and negatively. However, social support is given as the regression analysis on independent functioning shows: very old Romanians are more dependent, but they also receive more social support. In an Eastern European study, a considerable level of emotional support was found between adult children and their elderly parents; this support did continue in difficult times.8 Besides the crucial role of education and social support, neuroticism and extraversion related to the health of older Romanian adults. The relationship between neuroticism and extraversion, and health components is in line with other studies, which show that neuroticism is associated with more reported medical (chronic) problems and is negatively related to psychological health.25,43 Marital status was not related to health components, whereas sex was only related to suffering from chronic conditions. In a Polish study, a strong relationship was found between socioeconomic status and self-rated health.22 A Dutch study showed an important role of marital status and income in deterioration of functioning among older adults.44 More longitudinal research is required to understand the role of various independent variables on health components when people are aging. The three components show that health is more than the absence of diseases. Our data show that besides the “chronic disease” component, there is a psychological and a social component. This finding supports the discussion about whether health should be considered as a state or as an ability.45 The present findings show that health status is an ability; that is, an interaction between | 931
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chronic diseases, functional activities and psychological health determined by the social and physical environment older adults live in. Health status does differ individually and collectively in different cultures and health care systems. Therefore, it is important to have reliable data to assess the health status of citizens in each country, and to evaluate the health care system.3 Our data support the importance of assessing the health care needs of older adults in various domains of life.20,46 Data on various aspects of health in older adults living in CEE countries are scarce. The present study presented such data for Romania. We consider the study to be representative of older Romanian citizens because we used a stratified sample based on national population statistics; that is, with regard to sex and age, the present sample represents all older Romanian adults. We achieved a high response rate (91.2%), and did not find significant sex or age differences between responders and non-responders; this strengthens the representativeness of the sample. A high response rate is not unusual for surveys in CEE countries.47,48 Limitations of the present study included the crosssectional design and sampling from one metropolitan area. Longitudinal studies are required to understand the development of health in older age, and the relationship between (changes in) health and development in psychological and social factors. Such studies are scarce. Because this sample was taken from the greater metropolitan area of Bucharest, the infrastructure in which the respondents live differs from that of older adults not living in big cities. However, for all Romanian older adults, accessibility to (health care) services is difficult because of the co-payment, waiting lists and shortage of personnel/equipment, whereas their retirement income is low, as was discussed in the Introduction. Therefore, we believe the findings of the present study are representative for older Romanian adults. Also, we can compare these data with a few studies from other CEE countries, because we used the same design and methods. The present study is unique in the Romanian context. The survey covered various health aspects using internationally validated measures. Such a survey, with validated instruments and trained interviewers, is not common in CEE countries. Further research in this field is strongly recommended. As mentioned, such research should follow a longitudinal design. Also, further theoretical explorations and testing are required. Given the continuous emotional support of adult children, it could be very interesting to test findings of other studies in the Romanian context.8,30 Also, the role of social conditions on the development of health needs further research. For such international, comparative research using the same design and the same set of validated instruments, it is recommended that those countries with significantly different “social 932 |
conditions” be selected. Much European research in this field is limited to “Western” welfare states. The three health components could be used in primary health care to comprehensively assess the health care needs of elderly citizens. Such an assessment opens up a variety of ways for interventions within the existing Romanian health care system to prevent further deterioration in health and frailty.49 Given the important role of social support in relation to health care needs, a policy to maintain social (familial) networks is strongly recommended. The data are of utmost importance for Romanian policy makers. The comparison with data from other European countries shows that older Romanian adults will benefit from improvements in accessibility to health care and in the quality of health care services. Policy makers should give priority to such improvements in the health care system. Actually, health care policy is largely absent in Romanian policy.
Disclosure statement The authors declare no conflict of interest.
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