Associations between and coexistence of disadvantages in the oldest old people in Sweden: Patterns of change between 1992 and 2011

Abstract

This study explored changes in the associations between and coexistence of disadvantages in several dimensions of living conditions in the oldest old people in Sweden. We used nationally representative data from 1992 (n = 537), 2002 (n = 621) and 2011 (n = 931). Indicators of limited social resources, limited political resources, limited financial resources, psychological health problems, physical health problems and functional limitations were used. The probability of reporting coexisting disadvantages tended to increase and was particularly elevated in 2002. Physical health problems became more common, and functional limitations, limited financial resources and limited political resources became less common during the studied period. Associations between health-related disadvantages remained fairly stable, whereas associations including other kinds of disadvantages varied somewhat over the studied period. These changes suggest that in general, the composition of coexisting disadvantages is likely to have altered over time. Consequently, the challenges faced by disadvantaged groups in 2011 may have been different from those in 1992. Moreover, the healthcare and social care services directed to older people have undergone significant changes during the past decades. These changes to the system accentuate the vulnerability of people experiencing coexisting disadvantages.

Keywords

Coexisting disadvantages eldercare living conditions old age social exclusion Sweden

Introduction

For decades, the populations have been growing older in a number of countries. In Sweden, as in many countries across the world, the fastest growing part of the population is people aged 80 years and older (United Nations, 2013). People of advanced old age are susceptible to disadvantage in several life domains (Dean, 2009). In other words, in old age, we might be more susceptible to poor economic resources, to various forms of ill health and to experience social isolation. Older people are also more likely than younger to simultaneously experience disadvantage in two or more such life domains or dimensions of living conditions (Heap et al., 2013; Tsakloglou and Papadopoulos, 2002), a phenomenon that is here termed coexisting disadvantages. Older people who experience coexisting disadvantages may need support from various service providers and institutions of the welfare system – eldercare and healthcare are among the systems of central importance in this context. Cohort replacement is likely to affect the prevalence and coexistence of disadvantages in the older population over time, and consequently change the need for service and support.

Little is known about the development of coexisting disadvantages over time in the oldest part of the population. In this study, we examined coexisting disadvantages in the oldest old people in Sweden between the early 1990s and the early 2010s. The Scandinavian tradition of welfare research served as our analytical point of departure. The healthcare system and the social services system directed towards helping older people have undergone significant changes during the past decades. We discuss our empirical results in light of these changes.

Coexisting disadvantages and the Swedish welfare state

It seems reasonable to assume that disadvantage in one life domain (e.g. limited financial resources or physical health problems) restricts a person’s ability to manage related activities or challenges. It is more difficult to argue that experiencing disadvantage in two life domains is twice as bad as experiencing disadvantage in one. Nevertheless, it seems likely that coexisting disadvantages create extra challenges that hamper the general ability to manage everyday life. One way of grasping the extent of coexisting disadvantages is to analyse their prevalence in the population. However, as noted by Burchardt et al. (2002), the proportion of the population reported to be disadvantaged in a given life domain is affected by the threshold researchers use to signify disadvantage. Accordingly, such thresholds affect the prevalence of coexisting disadvantages. Rather than focusing solely on prevalence rates, Burchardt et al. (2002) suggest that we should study the relationship between disadvantages in different life domains, to obtain an indication of the extent to which disadvantages overlap. Indeed, Esping-Andersen (2000) has argued that in welfare research, ‘it is the welfare correlates that matter’ (pp. 6–7).

It has been suggested that correlated disadvantages are the most substantial form of inequality. Overall inequality is argued to be more extensive if, for example, the people who are poor are the ones who are in ill health than if those who are financially well-off are the ones who most commonly experience ill health (Fritzell and Lundberg, 2000; Sen, 1992; Walzer, 1983).

A principle inherent in the Swedish welfare state’s system is the assumption that one disadvantage should not lead to another. Analysing correlations between disadvantages may thus be informative from a social policy perspective, since the presence of correlations demands a different social policy approach to the absence of correlations (Erikson and Tåhlin, 1987; Esping-Andersen, 2000). It has been argued that if disadvantages tend to be correlated, policy should be directed towards helping individuals out of more generally disadvantageous circumstances, based on an understanding of their overall living conditions. If disadvantages seem to be uncorrelated, policy actions may be targeted at specific problems. Moreover, if certain disadvantages can be identified as underlying drivers, in the sense that they generate further disadvantages, these specific drivers may be targeted to mitigate other problematic conditions (Erikson and Tåhlin, 1987). However, before underlying drivers can be identified, causal relationships between disadvantages must be established. Establishing such relationships can be difficult. Moreover, it is plausible that older people experience several disadvantages that are not causally linked. Thus, for older people, perhaps the most important policy action is to provide support to help maintain independence in everyday life. To this end, the eldercare system is crucial, since it provides home-help services and institutional long-term care.

Since the 1990s, both the eldercare and the healthcare systems in Sweden have changed considerably. Several patterns can be found in these changes. One apparent trend is deinstitutionalisation. Between the early 1990s and 2010s, the number of hospital beds was cut down by half (National Board of Health and Welfare, 2015). Guided by the principle of ‘ageing in place’, that is, in the community instead of in institutions, the number of places in municipal institutional care was also reduced during this period. Moreover, the allocation of public needs-tested home-help services has become more restricted, and is now concentrated around people with the greatest needs (Sveriges Kommuner och Landsting (SKL), 2014). In parallel, a trend of re-familialisation has been identified: an increasing proportion of older people receive informal care from family members and friends (Ulmanen and Szebehely, 2015). A third major trend is marketisation. Since the 1990s, several central welfare services, including healthcare and eldercare, have been opened up to private service providers. Customer-choice models have been implemented and the number of service providers has increased.

Changes over time in coexisting disadvantages: the case of Sweden

Several previous studies from Sweden have shown that the proportion of the general population that reported coexisting disadvantages changed over time. For example, a substantial decrease in the proportion of people reporting three or more disadvantages was found between the late 1960s and early 1980s (Erikson and Tåhlin, 1987). It has also been found that between the 1970s and 1990s, the prevalence of two or more disadvantages decreased, followed by a slight increase in 2000 (Korpi et al., 2007). However, other studies showed that the prevalence of two or more disadvantages remained stable (fluctuations limited to around one percentage point) between the 1970s and the early 2000s (Bask, 2010).

Studies of shorter time periods show more detailed patterns of change. For example, the prevalence of coexisting disadvantages increased between the early and mid-1990s, decreased slightly by the end of the 1990s and remained stable between the end of the 1990s and mid-2000s (Ferrarini et al., 2010; Fritzell et al., 2007; Fritzell and Lundberg, 2000). These patterns suggest that societal changes such as the economic recession of the early 1990s can be reflected in the prevalence of coexisting disadvantages. Moreover, changes over time may differ by population subgroup. For example, several studies have found that the proportion of single parents experiencing coexisting disadvantages increased over several decades (Bask, 2010; Fritzell et al., 2007). Less is known about the changes over time in older people, as the oldest part of the population was generally excluded from the abovementioned studies.

Studies of changes over time in older people’s living conditions have often only considered one life domain at a time. Patterns over time differ between domains and specific indicators. In Sweden, older people have a higher educational level today than previously (Parker and Agahi, 2013), and since the 1990s, their average income has increased (Gustafsson et al., 2009). However, it has also been noted that between 2005 and 2013, so-called at-risk-of-poverty rates increased substantially in older women in Sweden relative to other European countries (European Commission, 2015). Moreover, life expectancy continues to increase worldwide, but studies of health trends have differing results, depending in part on which indicator is used. Internationally, the prevalence of chronic diseases has generally increased since the 1990s, but analyses of disability and limited physical functioning have yielded varying results (Crimmins and Beltrán-Sánchez, 2011; Galenkamp et al., 2013; Martin et al., 2012; Parker and Thorslund, 2007). In Sweden, the frequency of psychological health problems and certain measures of physical health problems (e.g. lung function) increased between 1992 and 2011, but the frequency of activity of daily living (ADL) limitations (limitations in daily living) decreased during the same period (Fors et al., 2013). Moreover, studies that use composite measures of ill health have found that prevalence rates of complex health problems (coexisting symptoms, diseases and functional limitations) have increased in recent decades (Meinow et al., 2015). Despite these studies, we still know little about whether the occurrence of coexisting disadvantages has changed over time in older people.

In people of working age, limited financial resources are often associated with several other disadvantages (Bask, 2016; Halleröd and Bask, 2008; Korpi et al., 2007). Studies of several periods from the 1990s to the mid-2000s have found that the association between limited financial resources and physical health problems tended to grow stronger (Bask, 2011; Fritzell et al., 2007; Fritzell and Lundberg, 2000). However, associations between other disadvantages have remained stable across two very different periods: the late 1960s to the early 1980s and the 1990s (Erikson and Tåhlin, 1987; Fritzell and Lundberg, 2000). Although the prevalence of coexisting disadvantages decreased considerably between the late 1960s and early 1980s, it increased during the recession years of the 1990s. This pattern had no clear influence on the associations between disadvantages: the proportion of the population with coexisting disadvantages changed, but the associations between the disadvantages remained similar – a result that underscores the usefulness of studying both phenomena.

Studies of older people have found that physical health problems are often one component of coexisting disadvantages (Heap et al., 2013; Whelan and Maître, 2008), perhaps because of the high prevalence of physical health problems in older people. Moreover, psychological health problems and limited financial resources are less prevalent but often appear in combination with other disadvantages (Heap and Fors, 2015). Studies of changes over time in the associations between disadvantages among the oldest old people are sparse.

In sum, previous research shows that in the Swedish population of working age, the prevalence of coexisting disadvantages decreased between the late 1960s and early 1980s, increased in the 1990s and remained fairly stable between the 1990s and 2000s. The associations between different disadvantages have remained comparatively stable throughout. Limited financial resources are a central component of coexisting disadvantages in the population of working age. Less is known about coexisting disadvantages in older people, but studies have shown that health problems are dominant in the coexistence of disadvantages. Moreover, the prevalence of health problems has increased in the older population during recent decades.

Aim

The overall aim of this study was to explore the question of whether coexisting disadvantages have become more or less common in the older population during recent decades, and whether the associations between disadvantages have changed over time. We addressed this question by studying changes over a 19-year period in the coexistence of and correlation between disadvantages in the older population by making cross-sectional comparisons between 1992, 2002 and 2011. We analysed the prevalence of disadvantage and the associations between the various disadvantages in each survey year. Physical health problems, ADL limitations (limitations in daily living), psychological health problems, limited financial resources, limited political resources and limited social resources were included in the analyses.

Because previous research suggests that the prevalence of several of the abovementioned disadvantages has decreased over time, it may seem likely that the prevalence of coexisting disadvantages has declined. However, any such decreased prevalence of disadvantages may not have been evenly distributed. It could have occurred mainly among people who previously experienced one disadvantage, which would lead to a higher prevalence of no disadvantages and a stable prevalence of coexisting disadvantages over time. The prevalence of physical health problems, unlike several other disadvantages, has increased in older people in recent decades, perhaps because more people live longer in ill health (Meinow, 2008). If more people experience physical health problems in old age, physical health problems may be added to the disadvantages individuals already have when they enter old age. This could imply that both the proportion of people who experience only physical health problems and the proportion that experience coexisting disadvantages will increase. Consequently, we hypothesised that the prevalence of coexisting disadvantages either remained stable or increased in the older population between 1992 and 2011.

Methods

Material

Data from the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) were used in this study. Data were drawn from three survey years: 1992 (n = 537), 2002 (n = 621) and 2011 (n = 931). In addition to the panel sample, new participants were recruited each year so that the total sample at each survey year was nationally representative of people aged 77+. The full samples from the three survey years were used to make repeated cross-sectional analysis to compare the three time points. People aged 85+ were oversampled in 2011. Sample weights were used to adjust for this oversampling in the analyses. Weights were also used to correct for an underrepresentation of people aged 77 in the 1992 survey.

Both community-dwelling people and people living in institutions were included in the sample. The response rate was 90.4 percent in 1992, 87.3 percent in 2002 and 86.2 percent in 2011. Most interviews were conducted face-to-face. When such an interview could not be carried out, telephone interviews or postal questionnaires were used. If a person was unable to answer the questions herself, an indirect interview with a relative or other close person was conducted. The SWEOLD study includes a wide thematic range of questions that cover several crucial aspects of living conditions. For a detailed description of the SWEOLD survey, see Lennartsson et al. (2014).

Dependent variables

In studies of older people, certain aspects of living conditions are more important – and other aspects less important than they are in studies of younger people. For example, labour market attachment is rarely relevant in studies of the oldest old people. Health, on the other hand, may be more fundamental in studies of the older than the younger population since health problems become more common with age. It is also more common for people in older age groups to experience coexisting health problems (Marengoni et al., 2011; Meinow et al., 2006). Because older people experience a wider range of health problems than do younger people, the number of health indicators included in the empirical studies of living conditions may be enlarged (Lundberg and Thorslund, 1996).

We thus chose to include a broad range of health indicators in the present study. Moreover, we separated several aspects of health that are sometimes incorporated in one domain: diseases and ailments (here termed physical health problems), limited physical functioning (here measured as ADL limitations) and psychological health problems. One reason for separating these aspects of health is to enable analyses of the relationship between them. Moreover, since these types of health problems are often treated by different healthcare providers, it may be relevant from a social policy perspective to broadly distinguish between them.

Physical health problems were measured with an index that contained one sub-index of circulatory problems and several items about other symptoms and diseases. All indicators were drawn from the question ‘Have you had any of the following illnesses or ailments during the past 12 months?’ This was followed by a list of specific health problems. Response alternatives were ‘Yes, severe’, ‘Yes, slight’ and ‘No’.

The sub-index of circulatory problems included items on chest pains, heart problems, high blood pressure, dizziness and coronary heart disease. Those reporting at least one of the following were considered to have circulatory problems: mild/severe coronary heart disease and/or one severe or three mild problems among the other items.

The following symptoms and diseases were measured using single items from the abovementioned list: severe problems with breathlessness, severe problems with diabetes, severe problems with vision/eye disease (that could not be substantially improved with glasses), mild or severe cancer, and mild or severe stroke.

In the overall index of physical health problems, people who reported circulatory problems and/or any of the problems measured with single items were classified as having health problems.¹

Psychological health problems were measured with three self-reported items. Respondents were asked whether they had experienced a number of ailments and diseases in the past 12 months, including nervous problems (anxiety, nervousness, distress), depression/deep sadness and mental illness. Response alternatives were ‘Yes, severe’, ‘Yes, slight’ and ‘No’. Those reporting at least one of the following alternatives were considered to have psychological health problems: severe nervous problems, severe depression and mild or severe mental illness.²

ADL limitations were measured with five questions about the respondent’s ability to perform various tasks with or without the help of another person. The tasks were eating, toilet visits, dressing and undressing, getting into and out of bed, and hair washing. Those who needed help from another person with one or more tasks were considered to have ADL limitations.

Limited financial resources were operationalised as a financial buffer. Respondents were asked whether they would manage to come up with a certain sum of money within a week’s time. The sum, adjusted to have the same purchase value in the different survey years, was 10,000 Swedish crowns in 1991, 12,000 in 2002 and 14,000 in 2011. Those who were unable to obtain the sum of money by drawing on their own resources – through a withdrawal from their own bank account or by selling stocks and shares – were classified as lacking financial resources.

Limited political resources reflect an inability to take political action and influence one’s living situation (Johansson, 1970). Respondents were asked ‘Would you be able to write a letter by yourself to appeal a decision made by a public authority?’ (response alternatives ‘Yes’ and ‘No’). Respondents who answered ‘No’ were asked a follow-up question, ‘Do you know anyone who could help you write such a letter?’ Those who answered ‘No’ to both questions were considered to have limited political resources.

The question about the ability to write a letter of appeal was not included in proxy interviews in 1992. In 1992, the internal non-response to the question about limited political resources was 13 percent, which was higher than for most other disadvantages (for which internal non-response ranged between 0.6 and 5.8 percent).

Limited social contacts were measured as frequency of meeting friends, children and grandchildren. Respondents were asked whether they usually visited friends and whether they usually had friends over for visits. Response alternatives were ‘Yes, often’, ‘Yes, sometimes’ and ‘No’. Also, respondents were asked how often they met and spent time with their children and how often they met and spent time with their grandchildren/great grandchildren. Response alternatives were ‘Daily’, ‘Several times a week’, ‘A few times a week’, ‘A few times a month’, ‘A few times a quarter’ and ‘Seldom or never’. If respondents did not have children or grandchildren, this was noted.

Respondents were regarded as having limited social contacts if they

Reported that they usually did not visit friends and did not have friends over for visits, answered ‘a few times every quarter year’ to one of the questions on social contacts with children and grandchildren, and ‘very seldom/never’ to the other question on social contacts with children/grandchildren; or

Answered ‘yes, sometimes’ to one of the questions on social visits with friends, answered ‘no’ to the other question on social visits with friends, and reported that they very seldom/never met with their children and grandchildren (or did not have any children/grandchildren).

In 1992, the questions on social visits with friends were not asked of people living in an institution. For these respondents, values were imputed. The imputation was based on the difference in contacts with friends between people living in the community and people living in an institution in 2002, taking into consideration the respondent’s gender and whether or not they had children. Details are available from the authors upon request.

The question on spending time with grandchildren was not included in the questionnaire that was used by 70 people as an alternative to face-to-face interviews in 2011. We found it unsuitable to make imputations for those who had been interviewed by questionnaire, since people chose to answer the questionnaire for varying and sometimes unknown reasons. Instead, we excluded those respondents. This made the internal non-response on the variable limited social contacts higher in 2011 (11.6%) than in other years.

Independent variables

Age was included as a continuous variable in the logistic regression analyses presented in Table 2. Stratified regressions and correlation analyses were also performed; in these analyses, age was included as a dichotomous variable (the age groups were 77–84 and 85+).

Gender was included as a control variable in the analyses presented in Table 2 and in the stratified regressions and correlation analyses.

Marital status was included in the stratified analyses. Because of the relatively low sample sizes, the variable was dichotomised. A division was made between people who were married or cohabiting and those who were not. The latter group comprised people who had never been married, divorced/separated people and widowed people.

Data analysis

To analyse the occurrence of disadvantages we calculated prevalence rates and performed logistic regression analyses. To facilitate interpretation and comparison between models, we transformed the odds ratios into average marginal effects (AMEs). To investigate the associations between different disadvantages, we used gamma correlations because these were possible to calculate with probability weights.

Results

Changes in prevalence of disadvantage

The first aim of this study was to analyse changes in the prevalence of disadvantage between 1992, 2002 and 2011. As seen in Table 1, it became less common to report no disadvantages, and the prevalence of one disadvantage increased slightly over time. The prevalence of coexisting disadvantages, that is, two or more disadvantages, increased by more than 10 percentage points between 1992 and 2002 and decreased in 2011 (but remained higher in 2011 than in 1992). Throughout this period, the differences in prevalence rates became smaller: in 1992, it was most common to report no disadvantages followed by one disadvantage, while in 2011, the prevalence rates for no disadvantages and one disadvantage were very similar.

Table 1.

Frequency and prevalence^a of each disadvantage in 1992, 2002 and 2011.

	1992		2002		2011
	n	%	n	%	n	%
No disadvantages	181	41.2	168	29.1	239	36.0
One disadvantage	149	33.9	199	34.2	256	35.6
Two or more disadvantages	109	24.8	198	36.7	235	28.4
Physical health problems	193	37.1	295	48.8	428	46.5
ADL limitations	154	29.1	190	32.2	278	25.3
Psychological health problems	43	8.2	67	11.4	95	11.0
Limited financial resources	95	18.3	105	17.6	99	13.2
Limited political resources	58	12.4	85	14.7	42	4.7
Limited social contacts	40	7.6	47	7.9	71	7.6

ADL: activity of daily living.

Weighted to adjust for an underrepresentation of people aged 77 in 1992 and an overrepresentation of people aged 85+ in 2011.

In each year, the physical health problems disadvantage was the most common, followed by ADL limitations (limitations in daily living) and limited financial resources. Still, the prevalence of each disadvantage varied over time. The prevalence of physical health problems increased over the study period. On the other hand, the prevalence of ADL limitations, limited financial resources and limited political resources decreased between 1992 and 2011. The low proportion of people who reported limited political resources in 2011 (4.7%) is worthy of note. The prevalence of psychological health problems increased slightly between 1992 and 2002 and remained stable between 2002 and 2011. The prevalence of limited social contacts was very similar in all survey years.

To adjust for changes in age and sex composition in the different survey samples, age and sex were included as control variables in the logistic regression analyses. The results are shown in Table 2 as AMEs. AMEs are interpretable as the average difference in the probability of the outcome depending on the value of the independent variable. In Table 2, the outcome is number of disadvantages or specific dimensions of disadvantage, and the independent variable is year of the survey. For example, the AME of −0.099 for reporting no disadvantages in 2002 is interpreted as meaning that the probability of reporting no disadvantages in 2002 was, on average, 9.9 percentage points lower than in 1992. The AME of 0.093 for reporting coexisting disadvantages in 2002 indicates that the probability of reporting coexisting disadvantages was (on average) 9.3 percentage points higher in 2002 than in 1992.

Table 2.

Probability of experiencing disadvantage in 1992, 2002 and 2011. Average marginal effects (AMEs) derived from logistic regression analyses controlled for age and sex.

	No disadvantages		One disadvantage		Coexisting disadvantages		Physical health problems		ADL limitations		Psychological health problems		Limited financial resources		Limited political resources		Limited social resources
	AME	p-value	AME	p-value	AME	p-value	AME	p-value	AME	p-value	AME	p-value	AME	p-value	AME	p-value	AME	p-value
1992	Ref		Ref		Ref		Ref		Ref		Ref		Ref		Ref		Ref
2002	−0.099	0.001	0.006	0.845	0.093	0.001	0.104	0.000	0.006	0.832	0.031	0.081	−0.006	0.800	0.020	0.361	−0.002	0.914
2011	−0.022	0.475	0.021	0.502	0.004	0.893	0.078	0.007	−0.071	0.003	0.025	0.414	−0.053	0.015	−0.081	0.000	−0.005	0.745
n	1734		1734		1734		2004		2033		2016		1983		1923		1928

AME: average marginal effect; ADL: activity of daily living.

For a number of disadvantages, the patterns remained the same as the patterns of the pure frequencies reported in Table 1. There was a decrease in the probability of reporting no disadvantages in 2002 and a similar (although not statistically significant) tendency in 2011. Moreover, the probability of reporting coexisting disadvantages increased in 2002. Once we adjusted for age and sex, the differences between the survey years in the probability of reporting no disadvantages and of reporting coexisting disadvantages became smaller. In 2011, the probability of reporting coexisting disadvantages did not differ from the probability in 1992, but the raw prevalence rates in Table 1 suggested an increase in coexisting disadvantages in 2011. Thus, the change in the age and sex composition between the survey years (an increased mean age in the older population and different ratios of men to women) contributed to the increased probability of reporting coexisting disadvantages in 2011.

For most of the single disadvantages, the patterns over time were similar in the raw prevalence (Table 1) and the logistic regression analysis (Table 2), although some differences were slightly lower in the latter analyses. One result deserves mentioning. As shown in Table 1, ADL limitations were less common in 2011 than in 1992. After controlling for age and sex (Table 2), this decline was slightly accentuated. This was mainly attributable to the inclusion of age. One interpretation of this result is that since ADL limitations are strongly associated with older age, the increase in the mean age in the sample between 1992 and 2011 to some degree levelled out the decrease in ADL limitations.

Moreover, separate analyses were carried out (not shown, but available upon request), stratified by age group (77–84 and 85+), sex and marital status (married/cohabiting and not married/cohabiting; the latter group included those never married, divorced and widowed). In most groups, the pattern in number of disadvantages (no disadvantages, one disadvantage and coexisting disadvantages) was similar to the general pattern in Table 1. Married/cohabiting people stood out, as the probability of each outcome was comparatively stable over time in this group. Analyses of single disadvantages showed several differences between groups of people. All the subgroups followed the general pattern of a higher probability of reporting physical health problems in both 2002 and 2011. However, the increase in 2011 was considerably greater among not married/cohabiting people than married/cohabiting people. Moreover, all subgroups had a lower probability of reporting limited financial resources in 2011 than in 1992. This tendency was stronger in the older than in the younger age group, in women than in men and in not married/cohabiting people than in married/cohabiting people. The general pattern of a decrease in ADL limitations in 2011 was apparent in women and those not married/cohabiting but not in men and those married/cohabiting. Furthermore, the prevalence of psychological health problems remained stable over time in men but tended to be higher both in 2002 and 2011 in women.

Associations between the disadvantages

The second aim of this study was to explore whether people who experienced one disadvantage had an increased risk of experiencing additional disadvantages and whether such patterns may have changed over time. To answer these questions, we analysed correlations between the disadvantages in 1992, 2002 and 2011. Gamma was used because it is suitable for ordinal variables and because the analyses could be performed with probability weights (to adjust for an oversampling of people aged 85+ in SWEOLD 2011). Gamma values vary between −1 (perfect negative association) and 1 (perfect positive association). A positive association between two disadvantages indicates that they are likely to occur simultaneously, whereas a negative association suggests the opposite. It is important to stress that the occurrence of one or more disadvantages does not say anything about the relationships between the indicators. It could very well be that the prevalence of coexisting disadvantages increased while the associations between the disadvantages remained stable, or vice versa.

The results are shown in Table 3. The majority of the associations were positive. The analyses revealed both patterns of stability and patterns of change over time. Notable stability was found in the quite strong positive associations between the health-related disadvantages. The disadvantages that were not health-related also showed positive inter-correlations in all survey years, but several of these were only moderate in size.

Table 3.

Bivariate correlations (gamma) between disadvantages in 1992, 2002 and 2011.

	ADL limitations	Psychological	Financial	Political	Social
1992
Physical	0.50**	0.43**	−0.03	−0.01	0.38*
ADL limitations		0.60**	0.54**	0.36*	0.81**
Psychological			0.38~	0.31	0.65*
Financial				0.26	0.35~
Political					0.63*
Social
2002
Physical	0.43**	0.56**	0.17	−0.12	−0.06
ADL limitations		0.54**	0.38**	0.08	0.62**
Psychological			0.40*	0.13	0.36
Financial				0.42**	0.15
Political					0.46*
Social
2011
Physical	0.52**	0.39**	0.30*	−0.10	0.33*
ADL limitations		0.36*	0.24~	−0.43~	0.54**
Psychological			0.44*	0.53~	0.04
Financial				0.39	0.26
Political					0.31
Social

ADL: activity of daily living.

p < 0.01; *p < 0.05 ~ p < 0.1.

In all three survey years, physical health problems were mainly associated with ADL limitations and psychological health problems. In 2011, unlike previous years, physical health problems were also associated with limited financial resources. ADL limitations were associated with all the other disadvantages in 1992, including those that were not health-related. However, all associations except those with physical health problems weakened over time, and the association between ADL limitations and limited political resources changed from positive to negative between 1992 and 2011. In all three survey years, psychological health problems were mainly associated with physical health problems, ADL limitations and limited financial resources. In 1992, psychological health problems were also associated with limited social resources. This association was weaker in 2002 and no longer present in 2011. In 1992, limited social resources were associated with all the other disadvantages, but these associations weakened over time.

Analyses stratified by age, sex and marital status were also carried out for the correlations between the different disadvantages in each survey year. In all the subgroups, the general pattern described above of a moderate or strong correlation between physical health problems, ADL limitations and psychological health problems was seen in most survey years. In most subgroups, the association between ADL limitations and limited financial resources decreased over time. In all marital status groups and age groups, the association between physical health problems and limited financial resources increased over time. Gender differences were apparent in the association between psychological health problems and limited financial resources; in all survey years, this correlation was stronger in men than in women.

Discussion

Changes over time in the occurrence of disadvantages

In line with our hypothesis, the results showed that the proportion of people who reported coexisting disadvantages increased slightly between 1992 and 2011. This result could be attributed to a higher mean age in the older population of Sweden in 2011. The increase, however, was not seen in all the individual disadvantages. Physical health problems became more common during the study period, whereas the prevalence of ADL limitations (limitations in daily living) decreased over time. Although previous research on health trends showed inconsistent results, our findings were not surprising. Moreover, the prevalence of limited financial resources decreased over time. The prevalence of limited political resources (the inability to appeal a political decision) also decreased considerably, which might reflect the increased educational level in more recent cohorts of older people.

Changes over time in associations between disadvantages

Our results showed positive and relatively strong correlations between health-related disadvantages in every survey year. This pattern of associations, paralleled by the increase in physical health problems, could mean that the proportion of people with multiple health problems increased during the studied period. Such an assumption is supported by a previous study using the same data, showing that the proportion of the older Swedish population that experienced complex health problems (coexisting symptoms, diseases and functional limitations) increased between the early 1990s and early 2010s (Meinow et al., 2015). Because of the ageing population, an increased proportion also implies an increased number of older people with complex health problems. This puts pressure on the eldercare system, since such complex health problems require integrating different types of care services and treatments (Meinow et al., 2015).

Although the prevalence of limited financial resources decreased over time, this disadvantage was continuously and in some cases increasingly associated with health-related disadvantages. The latter finding echoes results of previous studies of people of working age, which showed an increasing association between limited financial resources and physical health problems in the population of Sweden over time (Bask, 2011; Fritzell et al., 2007; Fritzell and Lundberg, 2000). It is possible that negative selection into the group of people with financial difficulties has increased: previous studies have shown that, in general, older people have become better off financially, but financial inequality has increased (Gustafsson et al., 2009). It is also possible that limited financial resources may lead to physical health problems. If such underlying causality exists, then the increased association suggests that it has become more difficult for people with limited financial resources to maintain good health.

Some of the disadvantages that we intend to analyse may initially seem naturally linked. For example, physical health problems (i.e. symptoms and diseases) may lead to limitations in ADLs (ADL limitations). Nevertheless, it is possible to carry out interventions that lessen the scope of ADL limitations, thereby minimising the link between physical health problems and ADL limitations. Empirical studies have shown that changes over time in the prevalence of symptoms or diseases and ADL limitations follow different patterns (Fors et al., 2013; Martin et al., 2012), which indicates that these two aspects of health problems need not always coexist.

Changing care systems

One consequence of the deinstitutionalisation of healthcare and eldercare is that an increasing number of older people live at home, including people with multiple health problems (National Board of Health and Welfare, 2014). Thus, if these people need help in managing their everyday lives, it will be provided in their own homes. The marketisation of the welfare system has led to an increased number of available home-help service providers. Previous research has suggested that the social services system directed to older people is not very well suited for them, since it requires the ability to choose and navigate between different service providers – abilities that many older people who are most dependent on such services do not have because of declining physical and cognitive capacities (Meinow et al., 2011). Because of the restrictions made to the allocation of home-help services, where services are provided only to people with the greatest care needs, people with moderate needs have, over the past decades, increasingly sought help from relatives or purchased services in the private market (Larsson, 2007).

Taken together, the responsibility placed on individuals seems to have increased. To make informed choices between the numerous service providers, a person requires sufficient physical and cognitive capacities, or a social network from which she can get help. Moreover, when there is a dissonance between the need for help and the services that are provided, a person needs either social or financial resources to bridge that gap. Hence, people who experience coexisting disadvantages are particularly vulnerable when the emphasis on people’s own responsibility is increasing.

Strengths and limitations

A limitation of analysing disadvantage in categories of none, one, and two or more disadvantages is that it can be problematic to claim that a person who experiences coexisting disadvantages is worse off than a person who experiences disadvantage in only one life domain. One reason is that the diverse characteristics of disadvantages in different domains can make such comparisons difficult. It would also be problematic to rank individual disadvantages and claim, for example, that a rich, sick person has a higher (or lower) degree of wellbeing than a poor, healthy person. Hence, those working in the Scandinavian welfare tradition have been reluctant to merge several dimensions of welfare into a summarised measure (Fritzell et al., 2007). Nevertheless, it is reasonable to assert that every additional welfare problem is somewhat negative. If two people are equally poor but one of them also has serious health problems, then all other things being equal, the person with two problems has the worse wellbeing (Fritzell et al., 2007). Moreover, it is negative from an equality perspective if disadvantages tend to be concentrated in certain groups of people.

A strength of this study was a high response rate in all survey years. A high response rate is particularly valuable in survey studies, since non-response is generally more prevalent among disadvantaged than advantaged groups. A low response rate could thus lead to an underestimation of the prevalence of disadvantages and the correlations between them (Kelfve, 2015).

Concluding remarks

In sum, although the prevalence of several disadvantages decreased, the occurrence of coexisting disadvantages increased slightly between 1992 and 2011. The associations between the disadvantages examined here varied somewhat over time, but did in general remain fairly stable. This suggests that people who reported coexisting disadvantages in 2011 generally experienced a different composition of disadvantages than those who reported coexisting disadvantages in 1992.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support from the Swedish Research Council for Health, Working Life and Welfare: 2012-1704; 2016-07206.

Notes

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