Inequalities in Quality of Life
Among People Aged 75 and Over
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Research Team:	Ms Elizabeth Breeze
	Professor Astrid Fletcher
	Dr Paul Wilkinson
	Mr Chris Grundy
Duration of Research:	February 2000 - April 2001
Contact:	Ms Elizabeth Breeze Epidemiology Unit London School of Hygiene & Tropical Medicine Keppel Street London WC1E 7HT Tel:  +44(0) 207 927 2109 Fax: +44(0) 207 580 6897 Email:elizabeth.breeze@lshtm.ac.uk
Findings

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Background

The Government has proposed to 'tackle fundamental inequalities' by concentrating 'attention and resources on the areas most affected by air pollution, poverty, low wages .. which can make people ill in both body and mind'. However, as yet older people have not had the attention they deserve in this policy.

Health inequalities across socio-economic groups are well established among people of middle age but there is far less information for older people, especially those aged 75 and over. This is the fastest-growing age group of the older population and the group with the highest health and social service use. Research so far shows that there are some socio-economic differences in mortality and in long-term illness persisting into very old age and suggests that the patterns of influential socio-economic factors may differ by gender. Hitherto there has been no research which looks at self-reported quality of life (QoL) as the outcome in relation to socio-economic factors.

Chronic health problems are known to be a source of depression and poor QoL. Social support may attenuate adverse effects of these health problems but the evidence on this is mixed. We will address whether inequalities in disease, disability and health contribute to socio-economic variations in inequalities of QoL; also whether social support either ameliorates or exacerbates the variations.

Policy interventions can be aimed at individuals or communities. It is hypothesised that characteristics of the area might have an influence on QoL over and above that arising from individual circumstances. It is also possible that the impact of individual circumstances may differ according to the characteristics of the area.

Aims and Objectives

The aim is to investigate differences in quality of life (and various dimensions thereof) of older people by their socio-economic circumstances in late and mid life; and to identify the features which account for socio-economic variations thereby informing appropriate intervention strategies.

The objectives are:

	To investigate differentials in QoL by socio-economic factors among people aged 75 and over living in the community; and to assess whether gender and age are additional sources of variations in QoL.
	To identify personal factors which contribute to differentials in QoL, in particular morbidity, level of social contact and social support, and availability of help including informal care and health and social services.
	To investigate the interaction of personal and area measures of deprivation on QoL.
	To examine whether social class during mid life is associated with QoL in old age; and to investigate whether socio-economic circumstances experienced in old age modify any observed association with mid life measures.

Study Design

The project uses data collected as part of a cluster- randomised trial of the means of assessment and care of people aged 75 and over in the community. In 23 general practices patients took part in detailed QoL interviews and subsequently had assessments of their health which identified both clinical and social needs. Three well-established QoL instruments were used: the Sickness Impact Profile; the Philadelphia Geriatric Morale Scale; and the Medical Outcomes Study 36-item short-form survey. To reduce the burden on participants practices were randomised to receive one of three versions of the questionnaires. Some dimensions are common to all versions, the rest being divided between them. The socio-economic measures include standard items such as current housing tenure, and central heating together with perceptions of material deprivation such as financial problems. The assessment covers self-reports of problems which warrant further clinical assessment, such as severe symptoms, problems of hearing and sight, difficulties with activities of daily living, incontinence, depression, memory problems. The QoL interview includes detailed information on use of health and social services in the previous month, and information on levels of informal caring (frequency of help, relationship of the informal carer). Social support is measured by frequency of contact with friends, neighbours or relatives outside the household, and availability of a close confidante.

Each participant is classified according to various characteristics of the enumeration district in which they live, such as the Carstairs deprivation score and density of occupation. The area characteristics are linked to the individual's circumstances using Geographical Information Systems methods.

Multivariate statistical methods will be used and clustering allowed for. The interpretation will take into account the possibility of health selection.

Policy Implications

The information on prevalence of poor QoL in subgroups is an essential starting point in deciding whether to take forward health inequalities among older people as a public health issue of importance. The subsequent modelling of explanatory and mediating factors, particularly those which are amenable to action (e.g. social support, care services, and community regeneration) will contribute evidence to assist in deciding on appropriate points of intervention to improve QoL. In particular, the availability of area-level characteristics is pertinent to the Government's proposals for healthy neighbourhoods and Health Action Zones and to the Department of Health's Health Inequalities programme.