Abstract
Aim
We aim to assess the effects of the COVID‐19 pandemic on self‐reported health and quality of life among family caregivers of children with disabilities across Europe.
Design
Cross‐sectional study.
Methods
Data from the survey by the Eurocarers and IRCCS‐INRCA were used. The data were collected between November 2020 and March 2021 from 16 European countries. Data analysis was done using regression analysis to identify family caregivers' self‐reported health and well‐being predictors.
Results
This study included 289 caregivers. The mean age of children was 12 years. Their family caregiver's mean age was 44, and they were mainly women. Experience of lack of freedom predicted family caregivers' poor self‐reported health and quality of life. Children's interrupted health and social services also predicted family caregivers' poor self‐reported mental well‐being. Longitudinal evidence on the pandemic's effects and a diverse view of family caregivers of children with disabilities are needed to plan effective post‐pandemic health services and nursing practice.
No Patient or Public Contribution.
Keywords: covid‐19, family caregivers of children with disabilities, mental health, nursing, self‐reported health
1. INTRODUCTION
The coronavirus pandemic (COVID‐19) has affected several aspects of everyday life since early 2020. There have been millions of COVID‐19 cases and deaths across Europe (European Centre for Disease Prevention and Control, 2022). In addition, lockdowns and social distancing measures have severely affected health and well‐being (Andrés‐Romero et al., 2021; Green, 2020), which may require new social and healthcare services and guidance in nursing practice. Therefore, it would be essential to assess the effects of the pandemic on vulnerable groups to plan post‐pandemic acts. For example, families of children with disabilities may have been vulnerable to the pandemic's effects. Thus, these children have an increased risk of coronavirus, complications and death owing to pre‐existing vulnerabilities (United Nations Children's Fund, 2021). In addition, some risk factors are linked to their underlying conditions and potential inability to practice preventive measures, such as physical distancing or wearing a mask (United Nations Children's Fund, 2021). However, children with disabilities are a diverse group (United Nations Children's Fund, 2021). For instance, this group includes (a) children who were born with a genetic condition affecting physical, mental or social development; (b) children who have had a severe injury, nutritional deficiency or infection which have contributed to long‐term functional difficulties; (c) children with delays in development or learning disabilities and (d) children with mental health challenges, resulting from stressful life events (United Nations Children's Fund, 2021).
These children are usually taken care of by family caregivers, who provide care at home. Currently, around 2%–37% of the population across European countries provides informal care for children and adults (Eurocarers, 2021). A child's family caregiver is a more likely parent(s), usually a mother (Keilty & Cohen, 2015). Family caregivers provide personal care, including taking care of hygiene, physical activities, eating and dressing (Verbakel, 2018). Caregivers may also be responsible for assisting with rehabilitation and biomedical, physical, psychological and social health issues (Toledano‐Toledano & Luna, 2020), depending on the child's condition. Family caregivers are similarly responsible for the unique care needs around the clock (Keilty & Cohen, 2015). However, caring for a child with a disability or longitudinal illness is usually only one task. Thus, these family caregivers may also work outside the home and care for their other children (Kalliomaa‐Puha & Tillman, 2016).
Caring for a child with a disability is challenging and may affect family caregivers' health and well‐being. However, family caregivers of children with disabilities are sometimes seen as young and healthy, bearing their responsibilities (Keilty & Cohen, 2015). As a result, their adverse experiences have often been overlooked in policy and health care since the number of children's family caregivers is smaller than that of older adults (Keilty & Cohen, 2015). Nevertheless, the previous evidence shows that children's family caregivers undergo many negative experiences. For example, they have reported depressive symptoms, poor health, chronic conditions and poor sleep compared to parents of healthy children (Brehaut et al., 2009; Keilty & Cohen, 2015). Besides, family caregivers of children with disabilities have had many adverse outcomes due to the COVID‐19 pandemic. These outcomes include mental distress (Horiuchi et al., 2020), post‐traumatic stress symptoms (Beth S. Russell et al., 2022), physical exhaustion, higher caregiving burden (Zahaika et al., 2021), increased daily negative mood and illness (Gassman‐Pines et al., 2020). In addition, family caregivers have experienced decreased living standards (Zahaika et al., 2021), hardships, income and job loss (Gassman‐Pines et al., 2020), challenges of providing care at home without essential services and worry about the child's development (Neece et al., 2020). Also, a multi‐national sample of 491 family caregivers caring for children aged 5–18 demonstrated the unequal effects of COVID‐19 on female caregivers' mental health compared to male ones (Wade et al., 2021). Female caregivers reported, for instance, higher post‐traumatic stress symptoms than male caregivers. They also had pre‐existing vulnerabilities, such as a history of adverse childhood experiences (Wade et al., 2021).
Consequently, a growing body of evidence shows that regulations and measures of the pandemic have disproportionately affected families of children with disabilities (United Nations Children's Fund, 2021). However, the extent to which the pandemic has affected family caregivers of children in Europe remains unclear. The preliminary evidence has mainly focused on family caregivers of children in Brazil (Costa et al., 2022), Japan (Horiuchi et al., 2020), Palestine (Zahaika et al., 2021), the United States (US) (Gassman‐Pines et al., 2020; Houtrow et al., 2020; Neece et al., 2020; Russell et al., 2020) and the United Kingdom (UK) (Darlington et al., 2021; Onwumere et al., 2021).
European‐wide research is needed to provide evidence for nursing practice. Nurses are at the frontline taking care of these families, and they can connect them with their needed services and resources. The evidence could also benefit paediatric nurses encountering children with disabilities and their family caregivers. On the other hand, nurses need the skills and knowledge to identify vulnerable groups (Jackson et al., 2021). However, little is known about the pandemic's effects on family caregivers of children with disabilities, which may also affect the nurses' ability to face and guide these families in the healthcare setting. Evidence of the pandemic's effects would benefit family caregivers, their children and nurses who encounter them.
2. AIM
This research aims to assess the effects of the COVID‐19 pandemic on self‐reported health and quality of life among family caregivers of children with disabilities (aged 17 and younger) across Europe.
3. DESIGN AND METHODS
This cross‐sectional study uses data from Eurocarers and the National Institute of Health and Science on Ageing, Italy (IRCCS‐INRCA), including 2468 participants across Europe. The survey was conducted online in 10 different languages in the Czech Republic, Estonia, Finland, Germany, Italy, Portugal and Sweden, as well as ‘other countries’, including Austria, Belgium, France, Ireland, Luxembourg, Slovenia, Spain, Switzerland and the UK (Eurocarers/IRCCS‐INRCA, 2021). Currently, the official number of family caregivers is approximately 5% of the population in the Czech Republic, 7% in Germany, 12% in Finland, 12% in Portugal, 13% in Estonia, 14% in Italy and 22% in Sweden (Eurocarers, 2021).
We will use the same terms and concepts as Eurocarers, and the National Institute of Health and Science on Ageing have used in their questionnaire. For example, we will focus on self‐reported health outcomes and quality of life without validated measurement tools. There is also no established definition of ‘lack of freedom’, which is the term that the data uses, but we will discuss the topic further in the discussion section.
3.1. Recruitment and data collection
Eurocarers has previously described the recruitment of family caregivers and the details of data collection in their report (Eurocarers/IRCCS‐INRCA, 2021). However, in brief, the family caregivers were recruited in collaboration with Eurocarers' member organisations, partner organisations, and, for example, through Facebook groups and Twitter. The data were collected through an online survey. The survey was targeted to (a) European informal/family/unpaid caregivers who provide regular care and/or support for one or more care recipients and (b) family caregivers aged 18 and older. The exclusion criteria included caregivers who did not fit the inclusion criteria (Eurocarers/IRCCS‐INRCA, 2021).
The data collection period was between 24.11.2020 and 8.3.2021. The online survey contained 49 main questions, which included more detailed questions. Nevertheless, this survey did not use validated indicators. In addition, this survey includes only categorical and descriptive variables.
The goal of data collection by Eurocarers was twofold. First, they aimed to document and analyse the effects of the COVID‐19 pandemic on family caregivers. Second, they aimed to gather information on how to support family caregivers during the exceptional situation of the pandemic (Eurocarers/IRCCS‐INRCA, 2021).
3.2. Primary objective
This study will focus only on those family caregivers (n = 289) who cared for children (aged 17 and younger). The primary objective was to assess the link between the family caregivers' self‐reported outcomes of the COVID‐19 pandemic (i.e. reduced/interrupted contacts with friends, interrupted health/social services to care recipients, daily and only relationship with care recipients and lack of freedom) and the effects on family caregivers' self‐reported physical condition, mental well‐being, general health, quality of life, access to health and social services, working conditions and education or training conditions. The response options for the latter were ‘improved’, ‘unchanged’, or ‘reduced’. We selected the ‘reduced’ response and assessed which factors predicted family caregivers' reduced self‐reported health, well‐being, quality of life, access to health and social services, working conditions and education or training.
3.3. Data analysis
The aim was to describe the factors predicting family caregivers' reduced self‐reported health, quality of life and other conditions due to the COVID‐19 pandemic. Therefore, multivariate regression analyses were performed to identify predictors and outcomes. The predictors were reduced/interrupted contact with friends, interrupted health /social services to care recipients, daily and only relationship with the care recipient and the lack of freedom or feeling of being trapped at home. The outcomes were family caregivers' reduced physical condition, mental well‐being, general health, quality of life, access to health and social service, working conditions and education or training conditions during the COVID‐19 pandemic. Analyses were adjusted for age, gender and education. The cut‐off value for statistical significance was p < 0.05 (two‐tailed) with a 95% confidence interval (CI). The data were analysed with SPSS 26.0. Descriptive data were presented in numbers and percentages. Results were presented with odds ratios (OR) and 95% CI. We will not present country‐specific descriptive data since it has been done previously by Eurocarers (Eurocarers/IRCCS‐INRCA, 2021).
3.4. Ethical considerations
Family caregivers were asked for electronic consent, confirming that they had read the study purpose, participated voluntarily, and were at least 18 years old (Eurocarers/IRCCS‐INRCA, 2021). Family caregivers also knew that the survey results would be used European‐wide. In addition, all responses to the survey used in the study were collected anonymously (EU Regulation no. 679 of the European Parliament and the Council, of 27.4.2016 and the Helsinki Declaration, 2013).
4. RESULTS
4.1. Description of study participants
This study included 289 participants across Europe. Family caregivers of children with disabilities were mainly women (92%), and their mean age was 44 years (age range 27–72). In contrast, the children's mean age was 12 years (SD 4), and they were primarily family caregivers' children (92%). Children mainly had some neurological disability or learning difficulty, other long‐term health conditions or physical disability. These conditions were also overlapping (Table 1).
TABLE 1.
Background factors of family caregivers (n = 289).
| Sociodemographic factors of family caregivers | n (%) |
|---|---|
| Age, mean (SD) | 44.4 (7) |
| Range | 27–72 |
| Gender | |
| Male | 21 (7) |
| Female | 266 (92) |
| Prefer not to say | 2 (1) |
| Education level, year | |
| 1–5 | 3 (1) |
| 6–8 | 23 (8) |
| 9–12/13 | 106 (37) |
| 12/13+ | 157 (54) |
| Marital status | |
| Married/cohabitant | 233 (81) |
| Single/unmarried | 26 (9) |
| Divorced/separated | 27 (9) |
| Widow | 3 (1) |
| Health status | |
| Very poor or poor | 64 (22) |
| Neither poor nor good | 97 (34) |
| Quite good | 115 (40) |
| Very good | 13 (5) |
| Impact of caregiving on health | |
| No impact | 41 (14) |
| Positive impact | 31 (11) |
| Negative impact | 217 (75) |
| Primary caregiver for | |
| One person | 218 (75) |
| Two people | 58 (20) |
| Three or more than three people | 13 (5) |
| Care recipient | |
| Age, mean (SD) | 11.9 (4) |
| Range | 0–17 |
| Family caregiver's relationship to care recipient | |
| Son/daughter | 265 (92) |
| Grandchild | 6 (2) |
| Other | 17 (6) |
| Care recipient's health condition | |
| Neurological disability or learning difficulty | 229 (83) |
| Other long‐term health condition | 144 (55) |
| Physical disability | 138 (52) |
| Place of residence in relation to the care recipient | |
| In the same household | 265 (97) |
| Infected by coronavirus | |
| Care recipient | 19 (7) |
| Family caregiver | 47 (16) |
4.2. The effects of COVID‐19
Regarding family caregivers' health and quality of life, they reported worsened quality of life (77%), worsened mental well‐being (74%), worsened physical condition (57%) and worsened health status (56%) due to the pandemic. In addition, family caregivers were worried about the decline in the physical and mental health of the child (70%) (Table 2).
TABLE 2.
Pandemic's impact on family caregivers' self‐reported health, quality of life and other conditions (n = 289).
| n (%) | |
|---|---|
| Health status | |
| Improved | 4 (1.4) |
| Not changed | 121 (42.2) |
| Worsened | 162 (56.4) |
| Physical condition | |
| Improved | 15 (5.2) |
| Not changed | 109 (37.8) |
| Worsened | 164 (56.9) |
| Mental health/psychological state of mind | |
| Improved | 9 (3.1) |
| Not changed | 65 (22.5) |
| Worsened | 215 (74.4) |
| Quality of life | |
| Improved | 11 (3.8) |
| Not changed | 56 (19.4) |
| Worsened | 221 (76.5) |
| Social network/participation | |
| Improved | 8 (2.8) |
| Not changed | 41 (14.2) |
| Worsened | 240 (83.0) |
| Working conditions | |
| Improved | 23 (8.0) |
| Not changed | 148 (51.6) |
| Worsened | 118 (40.4) |
| The COVID‐19 pandemic has caused loneliness, social exclusion and isolation | |
| Strongly/quite agree | 203 (70.3) |
| Worried about decline in the physical and mental health of care recipient | |
| Strongly/quite agree | 202 (69.9) |
| Able to look after own health and well‐being | |
| Strongly/quite agree | 124 (39.4) |
Lack of freedom or feeling of being trapped at home was the main factor predicting family caregivers' worsened self‐reported health and quality of life. For example, lack of freedom predicted family caregivers' impaired self‐reported physical condition (OR 3.620, 1.794–7.305 95% CI), mental well‐being (OR 3.320, 1.641–6.720 95% CI), general health (OR 2.787, 1.423–5.460 95% CI) and quality of life (OR 4.394, 2.094–9.217 95% CI) (Table 3).
TABLE 3.
Factors associated with self‐reported impaired physical condition, mental well‐being, general health and quality of life among family caregivers during the COVID‐19 pandemic.
| Physical condition | p‐value | Mental well‐being | p‐value | General health | p‐value | Quality of life | p‐value | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | (95% CI) | OR | (95% CI) | OR | (95% CI) | OR | (95% CI) | |||||
| Reduced/interrupted contact with friends | 1.195 | (0.529–2.699) | 0.669 | 1.966 | (0.857–4.511) | 0.111 | 1.767 | (0.788–3.963) | 0.167 | 0.807 | (0.318–2.046) | 0.652 |
| Interrupted health/ social services to the care recipient | 1.191 | (0.676–2.099) | 0.545 | 2.421 | (1.146–4.001) | 0.017* | 1.444 | (0.824–2.528) | 0.199 | 1.885 | (0.979–3.627) | 0.058 |
| Daily and only relationship with the care recipient | 1.343 | (0.762–2.365) | 0.308 | 1.817 | (0.917–3.562) | 0.082 | 2.059 | (1.181–3.589) | 0.011* | 1.613 | (0.797–3.285) | 0.184 |
| Lack of freedom | 3.620 | (1.794–7.305) | <0.001*** | 3.320 | (1.641–6.720) | 0.001** | 2.787 | (1.423–5.460) | 0.003** | 4.394 | (2.094–9.217) | <0.001*** |
Note: Adjusted for age, gender and education.
CI, Confidence Interval; OR, Odds Ratio.
*p < 0.05; **p < 0.01; ***p < 0.001.
Moreover, a lack of freedom/feeling of being trapped at home predicted a lack of access to health and social services (OR 2.137, 1.092–4.183 95% CI). Similarly, children's interrupted health and social services predicted family caregivers' impaired self‐reported mental well‐being (OR 2.421, 1.146–4.001 95% CI). Furthermore, children's interrupted health and social services also predicted family caregivers' lack of access to their own health and social services (OR 3.590, 2.038–6.326 95% CI) (Table 4).
TABLE 4.
Factors associated with reduced access to health and social services, working conditions and education or training conditions of family caregivers during the COVID‐19 pandemic.
| Access to health and social service | p‐value | Working conditions | p‐value | Education or training conditions | p‐value | ||||
|---|---|---|---|---|---|---|---|---|---|
| OR | (95% CI) | OR | (95% CI) | OR | (95% CI) | ||||
| Reduced/interrupted contact with friends | 1.280 | (0.579–2.834) | 0.542 | 1.546 | (0.684–3.491) | 0.295 | 1.085 | (0.420–2.802) | 0.867 |
| Interrupted health and social services to the care recipient | 3.590 | (2.038–6.326) | <0.001*** | 0.831 | (0.481–1.433) | 0.505 | 1.929 | (0.973–3.822) | 0.060 |
| Daily and only relationship with the care recipient | 1.322 | (0.751–2.327) | 0.333 | 1.397 | (0.801–2.437) | 0.238 | 1.142 | (0.609–2.141) | 0.680 |
| Lack of freedom | 2.137 | (1.092–4.183) | 0.027* | 0.955 | (0.484–1.883) | 0.894 | 1.481 | (0.651–3.371) | 0.349 |
Note: Adjusted for age, gender and education.
CI, Confidence Interval; OR, Odds Ratio.
*p < 0.05; **p < 0.01; ***p < 0.001.
5. DISCUSSION
This study aimed to assess the effect of the COVID‐19 pandemic on health and well‐being and associated factors among family caregivers of children with disabilities across Europe. The evidence shows that most family caregivers experienced worsened health status, physical condition, mental well‐being and quality of life due to the pandemic. Similar evidence has been found in other studies. Thus, evidence from Palestine shows that family caregivers' physical, psychological and social challenges increased due to the pandemic, leading to an increased burden (Zahaika et al., 2021). Likewise, the evidence from the US shows an increased caregiving burden among caregivers of children (Gassman‐Pines et al., 2020). In addition, parents taking care of children with autism spectrum disorder have also reported changes in family dynamics. Thus, other children in these caregiving families longed for socialisation, had difficulty adapting to change and had limited effectiveness in remote learning (Huang et al., 2021; Stadheim et al., 2022).
One of the main factors associated with family caregivers' self‐reported health and quality of life was a lack of freedom or feeling of being trapped at home. There is no established definition for ‘lack of freedom’, but in this context, it can be seen as a situation where family caregivers experience that their caregiving task fully controls their life. The previous evidence shows that most adults and children had reduced time spent on leisure activities during the pandemic. In addition, they reported isolating themselves or their child from activities outside the home (Handberg et al., 2021). This may be one factor explaining the experience of lack of freedom by caregivers; they had to protect themselves and their children from the infection, which led to isolation. Therefore, they felt trapped at home. Also, there were interruptions in children's health and social services, which may have added an extra burden to caregivers and reduced their experience of freedom.
The present study indicates that the child's interrupted health and social services affected the family caregiver's mental well‐being. Therefore, family caregivers may have worried about the child's health and well‐being, which has led to mental challenges. Other evidence has similarly shown changes in parents' mental health since the pandemic, including worrying about their children's physical and mental health (Feinberg et al., 2022). Also, mothers and families with lower income levels were at particular risk for deterioration in well‐being (Feinberg et al., 2022). Correspondingly, previous evidence shows that the pandemic has led to the loss of therapies, home nursing, medical supplies and safe access to medical providers (Houtrow et al., 2020). This change in services may have caused uncertainty in family caregivers' life and support systems. For instance, poorer access to hospital visits and treatments affected children's physical health, especially those with neuromuscular disease, who would have needed physiotherapy (Handberg et al., 2021).
Therefore, rapidly implemented restrictions in health care, education and social activities led to deviations in family life, which may have also affected parents' ability to take care of their own health. In addition, the pandemic may have also affected the child's behaviour which may have caused more worry for caregivers. For example, a study conducted in Brazil shows that the COVID‐19 pandemic has increased, for example, children's misbehaviour, agitation, crying and trouble sleeping (Costa et al., 2022). Children's burdens due to the pandemic may have increased the demand for social and health services for both child and family caregivers. However, at the same time, services for family caregivers were temporarily deteriorated or discontinued across the globe owing to COVID‐19 (World Health Organization, 2021). For example, 39 (45%) countries responding to the World Health Organization's (WHO) survey reported disruptions to services for children and adolescents with disabilities or mental health challenges (World Health Organization, 2021). Also, family caregivers have experienced reduced support because of public health restrictions (Tennant et al., 2022). Family caregivers may have also limited their contacts by their own choice to reduce the risk of the virus for the child (Tennant et al., 2022). These changes in services and social contacts may have increased mental challenges for family caregivers. However, support services for family caregivers vary across Europe (Eurocarers, 2021), which has put them in unequal positions before the pandemic. Therefore, unifying the political arrangements regarding family caregivers in Europe would be necessary. These arrangements should be strong enough to ensure family caregivers' equal opportunities in society and support their health and well‐being.
This study's strengths include a large sample of family caregivers from numerous European countries. However, several limitations should be considered. First, this study does not have any validated measurement tools, which affects the reliability of the results, and concepts may not be accurately measured. Thus, the questionnaire by Eurocarers is based on caregivers' subjective experience during the pandemic.
Second, there was a limited amount of family caregivers' sociodemographic factors in the collected data. Therefore, we could not assess whether social disparities among this population would disproportionally affect some of the caregivers' self‐reported health and quality of life. This limitation can be significant since family caregivers are often presented as a similar group. Besides, their social factors affecting, for instance, mental health, are often underreported in caregiving literature (Savela et al., 2022). Moreover, the limited sociodemographic factors in the collected data are critical when considering the increasing health inequalities due to the pandemic.
Third, this study presents only a snapshot of the population during the pandemic. Therefore, we cannot determine family caregivers' health and well‐being outcomes. Besides, little is known if family caregivers' burden has deepened due to the ongoing pandemic and what the effects are on children. Therefore, in the future, we need a diverse view of family caregivers and longitudinal evidence with validated measurements on the effects of the pandemic on their health and quality of life.
Finally, we may conclude that this study provides essential evidence on the health and well‐being of family caregivers of children with disabilities across Europe during the pandemic, which is beneficial to health care and nursing practice. The study results show the vulnerability of family caregivers of children to the pandemic's effects on their health and well‐being. Therefore, future nursing practice should consider how to encounter these family caregivers in healthcare. Furthermore, since family caregivers of children with disabilities are not similar, a nursing practice could also consider assessing their social determinants of health. The topics around the pandemic are also linked to social justice, and nurses are called to address the issue (James et al., 2021). Then again, it is also required to consider the heavy workload of nurses during the pandemic. Consequently, there is a need to strengthen the nursing workforce to sustain public health (Jackson et al., 2021) and narrow potential pandemic‐induced health disparities. Nevertheless, we need more evidence on the pandemic's effects on family caregivers of children with disabilities to provide comprehensive evidence to nursing practice and health care.
6. CONCLUSIONS
Family caregivers of children with disabilities across Europe experienced worsened self‐reported health and quality of life due to the pandemic. The experience of lack of freedom predicted family caregivers' poor self‐reported health, mental well‐being and quality of life. Similarly, children's interrupted health and social services predicted family caregivers' poor self‐reported mental well‐being. These outcomes would require increasing attention in nursing and health care to tackle the consequences of the pandemic. First, however, we need longitudinal evidence on the effects of the pandemic and a diverse view of family caregivers of children with disabilities to plan effective post‐pandemic services through nursing practice.
FUNDING INFORMATION
The first author received funding from Jenny and Antti Wihuri Foundation and the Finnish Cultural Foundation.
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest to declare.
ACKNOWLEDGEMENTS
We thank Eurocarers and IRCCS‐INRCA—National Institute of Health and Science on Ageing, Italy, for the data access.
Savela, R.‐M. , Nykänen, I. , & Välimäki, T. (2023). Lack of freedom predicted poor self‐reported health among family caregivers of children with disabilities during the COVID‐19 pandemic in Europe. Nursing Open, 10, 5177–5184. 10.1002/nop2.1753
DATA AVAILABILITY STATEMENT
The data are available from the corresponding author upon reasonable request with the permission of Eurocarers and IRCCS‐INRCA ‐ National Institute of Health and Science on Ageing, Italy.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data are available from the corresponding author upon reasonable request with the permission of Eurocarers and IRCCS‐INRCA ‐ National Institute of Health and Science on Ageing, Italy.