Healthcare renunciation among Italian older adults during the COVID-19 pandemic: insights from the PASSI d’Argento surveillance system

Abstract

During the COVID-19 pandemic, a noticeable decrease in medical care utilization occurred which may contribute to increased morbidity and mortality rates associated with treatable conditions. In Italy, severely impacted by the pandemic, a comprehensive data source on healthcare renunciation is essential for policy formulation and intervention strategies. This study used data from the PASSI d‘Argento (PdA) surveillance system to investigate healthcare renunciation among people aged ≥65 years in Italy from August 2020 to December 2021 and to estimate the health and sociodemographic profiles associated with barrier-renunciation (due to service disruption) and refusal-renunciation (because of fear of contagion). A total of 4364 out of 10 827 individuals needing healthcare reported foregoing at least one medical visit or diagnostic test, with the major reasons being fear of COVID-19 contagion (33%) and service disruptions (29%). Sociodemographic inequalities existed: regression analysis revealed significant associations between healthcare renunciation and being female [adjusted prevalence ratio (aPR) 1.17, 95% CI: 1.08–1.26], reporting economic difficulties (aPR 1.15, 95% CI: 1.02–1.28), having two or more chronic conditions (aPR 1.18, 95% CI: 1.04–1.34), and having at least one sensory problem (aPR 1.13, 95% CI: 1.06–1.22). Compared to 2020, healthcare renunciation decreased in 2021. The relevant healthcare renunciation among elderly in Italy during the pandemic highlights widening health gaps and barriers to care access. Long-term monitoring tools are crucial to mitigate the pandemic’s impact on public health, especially for vulnerable populations.

Introduction

In early 2020, the Coronavirus disease (Severe Acute Respiratory Syndrome Coronavirus 2, SARS-CoV-2) outbreak rapidly escalated, leading the World Health Organization (WHO) to declare it a global pandemic on 11 March 2020 [1]. Italy became the first European country to face this health emergency, and on 9 March 2020, the Italian Government implemented extraordinary measures to contain and combat the Coronavirus, including restrictions on movement throughout the entire national territory [2].

The emergency has had a substantial impact on healthcare systems worldwide [3]. The US Centers for Disease Control and Prevention (CDC) specifically advised reducing unnecessary medical care visits and utilizing alternatives to face-to-face treatment and visits [4].

The World Health Organization (WHO) conducted a survey among Ministry of Health officials in five WHO regions by sending questionnaires to 159 countries between May and July 2020 to evaluate the impact of the COVID-19 pandemic up to 25 essential health services. Results showed reasons of health services outages, how they were perceived and national approaches to overcome the disruptions. Nearly all countries (90%) experienced service disruptions, with low-income countries being particularly affected. The most frequently interrupted services included routine immunization services and hospital-based services (70%), community support services (61%), diagnosis and treatment of non-communicable diseases (69%), family planning and contraception (68%), treatment of mental health disorders (61%), antenatal care (56%), and cancer diagnosis and treatment (55%) [5].

In Italy, the National Health Service had to reorganize primary, territorial, and hospital care to allocate resources for COVID-19 patient assistance [6]. Concurrently, based on the Ministry of Health’s recommendations, the mode of assistance changed to handle the increased number of hospitalizations, restrict access to healthcare facilities, and safeguard the health of citizens and healthcare workers. Outpatient care and hospitalization were categorized as either “undeferrable” (aligned to national waiting list reference times according to the National Plan for Waiting Lists Governance—Piano Nazionale Governo Liste di attesa, PNGLA 2019–21) or “deferrable” (suspended and to be rescheduled later) [7].

In this context, pandemic-related impacts have significantly affected prevention efforts, particularly targeting the healthy population. Due to its non-urgent nature and deferrable characteristics, prevention measures have encountered challenges during the pandemic. As a result, the response to this situation has caused a sudden disruption of various routine care activities, including cancer screening tests that are designed for a clinically asymptomatic population [6].

Overall, accessing healthcare has significantly changed primarily due to preventive measures aimed at controlling the virus spread. Furthermore, the unpredictable and rapid spread of COVID-19 has triggered a universal sense of awareness, anxiety, and distress [8]. In Italy, it has been observed that the prevalence of depressive symptoms increased during the national lockdown [9].

A study conducted in September 2020 estimated that 41% of US adults refrained from seeking medical care during the pandemic due to concerns related to COVID-19. Among them, 12% did not access emergency or urgent care intentionally, whereas 31.5% forewent routine care [10]. These findings align with recent reports indicating a decrease in hospital admissions, visits to emergency departments, and medical consultations for conditions like heart attacks, strokes, and hyperglycaemic episodes since the onset of the pandemic [11]. In Italy, some specific studies detected the impact of closures in healthcare settings immediately after the national administrative order of 10 March 2020, such as a survey conducted by dental practitioners in the North that registered 92.7% of visits cancelled [12].

Nevertheless, healthcare renunciation could further increase the risk of morbidity and mortality linked to treatable and preventable health conditions. This behaviour may also play a role in the reported increase in deaths, whether directly or indirectly related to COVID-19.

This paper aims to understand how the healthcare renunciation occurred among the elderly population in Italy during the pandemic emergency, using data from the Italian national surveillance system, PASSI d‘Argento (PdA), which collects information continuously regarding health and health-related aspects in people aged 65 years and older [13]. Since August 2020, PdA has been investigating also some COVID-19-related issues also including healthcare renunciation for reasons related to COVID-19 [14], both in form of barrier-renunciation, due to service disruption, or refusal-renunciation, because of fear of contagion as well as for other reasons [15].

Methods

The PdA surveillance system

PdA is a nationwide cross-sectional survey based on interviews to people aged 64 years and over, aimed to provide nationally representative estimates on a wide range of indicators such as health status, behavioural risk factors, psychological and social well-being according to the concept of Active and Healthy Ageing [16]. PdA is based on the international framework of the US Centers for Disease Prevention, the Behavioural Risk Factor Surveillance Systems [17] and it is officially recognized as a surveillance system of national and regional relevance by the Decree of the Prime Minister’s Office on Registries and Surveillances, 3 March 2017 [18].

PdA was first tested in 2009, implemented as cross-sectional survey in 2012 and, since 2016, has been basing on a continuous data collection.

The National Institute of Health in Italy, referred to as Istituto Superiore di Sanità (ISS), is responsible for coordinating PdA at the national level. The operative hubs are the Local Health Units (LHUs), where specifically trained healthcare professionals conduct interviews with representative samples of the resident population. The sample is randomly selected from the LHU list of beneficiaries of health services of the proportionally stratified by sex and age (65–74, 75–84, 85 and over); non-eligibility criteria are: living in another region, not holding a valid telephone number, being currently hospitalized or in long-term care, nursing home or prison, and not being an Italian speaker.

Information is collected through a structured and standardized questionnaire divided into six thematic sections. Data provided by LHUs are merged and opportunely weighted to obtain representative national and regional estimates (a probability weight equal to the inverse of the sampling fraction in each LHU stratum is assigned to each record). Responses to the questionnaire were provided either directly by the elderly individuals or by proxy (a person close to the older that support him/her during the interview). The proxy is allowed only when the older adult reports difficulties at the beginning of the interview or fails a short memory test based on three orientation questions from the Mini-Mental State Examination.

Over the years, response rate has remained extremely high and, was more than 80% in 2020 and 2021 according to the parameters indicated by the guidelines of the American Association for Public Opinion Research [19].

Since August 2020, a specific COVID-19 module was added to the standard PdA questionnaire to investigate relevant aspects of the pandemic and its impact, such as emotional status regarding the COVID-19 pandemic, contagion and disease outcomes risk perception, Sars-CoV-2 vaccine attitudes, mask use, citizens’ trust in the LHUs’ ability to manage the emergency, and also healthcare renunciation both as form of barrier-renunciation, due to service disruption, or refusal-renunciation, because of fear of contagion, or for other reasons.

Demographic and socioeconomic characteristics of respondents are also available from PdA and allow to stratify the analyses.

Study variables and definitions

Healthcare renunciation was assessed by asking if, in the last 12 months, the respondent had forgone any medical or diagnostic examinations, he/she needed. The possible answers were: “Yes, at least once”; “No, I have completed all my medical or diagnostic examinations”; “No, I did not require medical or diagnostic examinations.” Respondents who reported that they did not require any visits or exams were not included in the study.

Participants who responded affirmatively (“Yes, at least once”), were further asked about the main reasons behind their renunciation behaviour, with a multiple-choice and open-ended question that allowed the interviewer to categorize the possible answers in: long waiting lists, costs, difficulty accessing services (due to the distance of the facility, lack of transportation, or uncomfortable hours), inability to leave the non-self-sufficient person being cared for, reasons related to work or health, disruption of services due to COVID-19 emergency and fear of being infected by COVID-19.

The sociodemographic variables considered in our analyses included the following:

• Age: 65–74, 75–84, and 85+ years.

• Gender: male and female.

• Education: low (none or elementary school), high (middle school or higher).

• Economic difficulties (economic difficulties in making ends meet by the available household financial resources): none, some, many.

• Area of residence: North, Centre, South.

The health status characteristics examined included:

• Chronic diseases: information retrieved by individual yes/no answering questions about having been diagnosed in their lifetime with diabetes, kidney failure, chronic bronchitis, emphysema, asthma, respiratory insufficiency, stroke myocardial infarction, coronary and other heart diseases, cancer, chronic liver disease or cirrhosis; none, at least one

• Sensory problem: having at least one problem among those related to chewing, vision, and hearing.

Data analysis

Data utilized in this study were obtained from interviews conducted between August 2020 and December 2021, through the questionnaire including the COVID module introduced during the pandemic. We focused on individuals reported needing a medical visit or diagnostic examination within the 12 months prior to the interview, whether they reported healthcare renunciation or not.

Distribution of sociodemographic characteristics, health status (presence of two or more chronic diseases, sensory problem), and the healthcare renunciation factors linked to the COVID-19 emergency were analysed.

Prevalence and adjusted prevalence ratios (aPRs) from Poisson regression analysis were estimated to analyse the characteristics associated with the healthcare—in terms of medical visits or exams—renunciation.

Then, two different Poisson models were used to identify, separately, the characteristics of the elderly who reported healthcare renunciation due to pandemic-related reasons, such as service disruptions or fear of contracting the COVID-19. aPRs are presented with corresponding 95% confidence intervals (95% CI). All data were analysed using STATA, version 16.0 (Stata Corp, College Station, TX, USA).

Results

A total of 18 049 interviews were collected in the period from January 2020 to December 2021. Out of these, 15 713 refer to the phase after the introduction of the COVID module in August 2020. Among them 4480 affirmed they did not require either visits or exams and were not included in the analyses and 406 had missing data on renunciation.

The remaining 10 827 interviewees stated that they needed a medical visit or a diagnostic exam in the 12 months prior to the interview and were included in the analysis: 4364 reported having forgone at least one medical visit or diagnostic test they needed instead 6463 declared they did not forgo any of the necessary visits or tests (Fig. 1).

Figure 1.

Flow chart for selected sample. Passi D'Argento 2020–21, Italy.

Among those who reported healthcare renunciation, the analysis on the reasons highlights that 33% exclusively cited the fear of COVID-19 contagion, 29% exclusively cited the services disruption due to emergency management, ∼6% cited both COVID-19-related reasons along with other reasons. About 32% of respondents reported other reasons, of these, one-third consists exclusively of long waiting lists and in the remaining cases, the elderly reported high costs, difficulties in accessing services, being a caregiver unable to leave the dependent person, reasons related to work or health status (Fig. 2).

Figure 2.

Healthcare renunciation: major reasons declared from the respondents - Passi D'Argento 2020–21, Italy n = 4364.

Sociodemographic and other characteristics of the 10 827 elders who would have needed a visit or exam are shown in Table 1: over half were females (57.9%), 49.1% of respondents were aged 65–74, 35.4% 75–84, 15.5% more than 85. About 61% of the sample had at most completed primary school, about 38% reported economic difficulties (31.5% some and 6.1% many), 31.4% were resident in regions of the North of Italy, 30.9% in the Centre, and 37.7% in the South. More than 65% of the sample reported having received at least one chronic disease diagnosis: 37.1% with one diagnosis and 28.3% with two or more. Nearly 3 out of 10 elderly individuals declared having at least one problem related to vision, hearing, or chewing.

Table 1.

Sample study weighted distribution (n = 10 827), prevalence, and adjusted prevalence ratio for people who reported healthcare renunciation (n = 4364).

Characteristics		Sample study		People who reported healthcare renunciation (N = 4364)
		Distribution		Prevalence		Poisson regression model
		N	%	%	95% CI	Adj. PR	95% CI
Total		10 827	100.0	39.8	38.31–41.31	–	–
Gender	Male	4671	42.1	37.0	34.43–39.57	1	–
	Female	6156	57.9	41.9	40.12–43.63	1.17	1.08–1.26
Age group	65-74	4632	49.1	42.8	40.21–45.33	1	–
	75-84	4111	35.4	39.2	37.09–41.25	0.90	0.83–0.98
	85+	2084	15.5	31.9	29.34–34.65	0.72	0.65–0.81
Educational levela	High	4380	39.2	41.8	40.19–43.45	1	–
	Low	6346	60.8	36.8	34.37–39.33	0.83	0.76–0.90
Economic difficultiesb	None	6734	62.4	37.9	35.77–40.06	1	–
	Some	3180	31.5	41.5	38.82–44.29	1.15	1.02–1.28
	Many	697	6.1	51.9	46.68–57.00	1.46	1.29–1.66
Geographic area of residencec	North	4436	31.4	43.8	41.92–45.67	1	–
	Centre	3055	30.9	32.3	30.16–34.53	0.82	0.74–0.91
	South	3336	37.7	42.6	39.40–45.88	1.08	0.98–1.18
Noncommunicable chronic diseases	None	3677	34.6	37.9	35.52–40.30	1	–
	1	4000	37.1	38.5	35.93–41.05	1.04	0.95–1.15
	2+	3130	28.3	43.5	40.68–46.42	1.18	1.04–1.34
Sensory problemd	No	7752	73.5	39.2	37.41–41.10	1	–
	Yes	3075	26.5	41.4	39.06–43.69	1.13	1.06–1.22
Period	2020	2802	29.0	49.6	46.83–52.43	1	–
	2021	8025	71.0	35.8	34.28–37.32	0.74	0.70–0.80

^aLow: No education or at most an elementary school diploma. High: At least a middle school diploma or higher.

^bSelf-reported difficulties in making ends meet by the available financial resources.

^cThe Southern Italy includes the two major islands (Sardinia and Sicily) as per census criteria by the Italian National Institute of Statistics.

^dSensory problem, yes: having at least one sensory problem among those related to chewing, vision, and hearing.

Among the elderly who would have needed a visit or exam, 4364 reported healthcare—as medical visit or diagnostic test—renunciation. The estimate is higher among women (41.9% vs. 37.0% among males), the elderly with a higher educational level (41.8%), and those reporting many economic difficulties (51.9%), among the 65–74 years aged (42.8%) compared to the elderly aged 75 and above. Other relevant conditions included living in the North (43.8%) or South of Italy (42.6%), suffering from two or more chronic diseases (43.5%), or at least one problem related to vision, hearing, or chewing (41.4%). In 2021, foregoing medical treatment decreased compared to 2020 (35.8% vs. 49.6%).

The Poisson regression analysis confirms as significant many of these differences: healthcare renunciation is significantly associated with being female (aPR 1.17, 95% CI: 1.08–1.26), reporting some (aPR 1.15, 95% CI: 1.02–1.28) or many (aPR 1.46, 95% CI: 1.29–1.66) economic difficulties, having two or more chronic conditions (aPR 1.18, 95% CI: 1.04–1.34), and at least one problem related to vision, hearing, or chewing (aPR 1.13, 95% CI: 1.06–1.22). As indicated by the estimated prevalence, healthcare renunciation significantly decreased in 2021 (aPR 0.74, 95% CI: 0.70–0.80) (Table 1).

The primary reasons given by respondents for healthcare renunciation were fear of COVID-19 infection and service interruptions (Fig. 2). To investigate these aspects further, regression analysis focused exclusively on answers attributing healthcare renunciation solely to service disruption or fear of COVID-19. To this purposes, two Poisson regression models were performed to analyse the profile of individuals who reported healthcare renunciation exclusively due to (i) service disruption and (ii) fear of COVID-19 infection, both in comparison to individuals who did not report any healthcare renunciation.

The results from the two Poisson regression models are presented in Table 2.

Table 2.

Results from two Poisson regression models: analysis of association between the socio-demographic variables, health status, and COVID-19-related factors with healthcare renunciation due to services disruption and fear of COVID-19.

		Poisson regression model
Characteristics		Services disruption versus elderly who did not report healthcare renunciation		Fear of COVID-19 versus elderly who did not report healthcare renunciation
		aPR	95% CI	aPR	95% CI
Gender	Male	1	–	1	–
	Female	1.14	0.99–1.31	1.32	1.13–1.54
Age group	65-74	1	–	1	–
	75-84	0.85	0.74–0.98	0.96	0.81–1.12
	85+	0.53	0.43–0.65	0.82	0.67–1.01
Educational levela	High	1.13	0.99–1.30	1.35	1.14–1.60
	Low	1	–	1	–
Economic difficultiesb	None	1	–	1	–
	Some	1.12	0.92–1.35	1.25	1.02–1.54
	Many	1.87	1.50–2.33	1.63	1.26–2.12
Geographic area of residencec	North	1	–	1	–
	Centre	0.34	0.27–0.42	0.93	0.79–1.09
	South	0.54	0.46–0.64	1.41	1.19–1.67
Noncommunicable chronic diseases	None	1	–	1	–
	1	1.14	0.96–1.35	0.96	0.79–1.15
	2+	1.25	1.01–1.56	1.04	0.81–1.34
Sensory problemd	No	1	–	1	–
	Yes	1.30	1.13–1.50	1.06	0.91–1.23
Period	2020	1	–	1	–
	2021	0.49	0.43–0.56	0.69	0.58–0.81

^aLow: No education or at most an elementary school diploma. High: At least a middle school diploma or higher.

^bSelf-reported difficulties in making ends meet by the available financial resources.

^cThe Southern Italy includes the two major islands (Sardinia and Sicily) as per census criteria by the Italian National Institute of Statistics.

^dSensory problem, yes: having at least one sensory problem among those related to chewing, vision, and hearing.

Medical care or diagnostic exams renunciation due to service interruptions was higher associated among elderly reporting significant economic difficulties (aPR 1.87, 95% CI: 1.50–2.33), those with two or more chronic diseases (aPR 1.25, 95% CI: 1.01–1.56), and respondents experiencing at least one sensory problem related to vision, hearing, or chewing (aPR 1.30, 95% CI: 1.13–1.50). On the contrary, residing in the Central (aPR 0.34, 95% CI: 0.27–0.42) and Southern regions (aPR 0.54, 95% CI: 0.46–0.64) compared to the North and being older than 75 years old (75–84: aPR 0.85, 95% CI: 0.74–0.98; 85+: aPR 0.53, 95% CI: 0.43–0.65) were associated with a lower medical care renunciation due to service disruption. This specific type of reason was reported by respondents less frequently during 2021 (aPR 0.49, 95% CI: 0.43–0.56), comparing to 2020.

Healthcare renunciation due to fear of COVID-19 infection is more strongly associated with being in the following conditions: female (aPR 1.32, 95% CI: 1.13–1.54), highly educated (aPR 1.35, 95% CI: 1.14–1.60), economically disadvantaged, both partly and strongly (some: aPR 1.25, 95% CI1.02–1.54; many: aPR 1.63 95% CI: 1.26–2.12), resident in Southern regions (aPR 1.41, 95% CI: 1.19–1.67) compared to the Northern areas. As for the other reason, during 2021, the renunciation levels due to fear decreased (aPR 0.69, 95% CI: 0.58–0.81).

Discussion

To our knowledge, the present article is the first extensive study that, building on strongly consolidated and structured data [15], examines the extent of healthcare renunciation among Italian elderly population during the COVID-19 pandemic and, more in particular, explores the profile of those who reported barrier-renunciation, due to service interruptions, or refusal-renunciation, because of fear of infection.

In European studies, the prevalence of renunciation during the pandemic showed high variability ranging from 20% to 44%, then showing clear differences among countries [20, 21]. This varying percentage might be explained by how severely and at which emergency stage each country was affected. In countries where the pandemic occurred in a later phase, it was possible to use the guidelines as well as prevention and control measures already implemented in countries like Italy, where the virus spread even before the WHO declared a global pandemic. In Italy, in fact, there have been multiple pandemic waves over time, affecting various regions differently, with the worst impact in the northern areas.

To our study, being advanced in years, being women, reporting economic difficulties, having high educational level, suffering from two or more chronic diseases and at least one problem related to vision, hearing, or chewing were associated with medical care renunciation during the pandemic. The apparently contradictory finding that healthcare renunciation was more common among highly educated individuals and those with economic difficulties highlights a complex interaction of factors. Higher education may lead to greater health risk awareness and perceived vulnerability, resulting in more cautious behaviour due to fear of infection. On the other hand, financial hardship poses concrete barriers to accessing care, regardless of awareness. Our findings are in agreement with the international literature [10, 22, 23].

PdA results highlight the actual and significant implications of healthcare renunciation under the perspective of health inequalities. The decision to forgo essential medical care can exacerbate existing health disparities, resulting in poorer health outcomes, particularly among the elderly. Furthermore, the pandemic has likely widened these disparities, as evidenced by its differential impact on various sociodemographic groups. Still, previous data from PdA surveillance, relating to the pre-pandemic period (2016–19), described elderly people having even greater difficulties in accessing basic health and social services, particularly those in advanced years or living in the South of Italy, which is the macro area with the most significant issues in the country. Additionally, access problems are prevalent among individuals with economic difficulties and lower levels of education, further exacerbating health disparities in these vulnerable populations [24].

Care renunciation includes two main types: barrier renunciation and refusal renunciation. Barrier renunciation happens when individuals face external obstacles, such as service interruptions, that prevent them from accessing care. Refusal renunciation occurs when individuals deliberately choose not to seek care even though it is available, often due to personal beliefs or preferences.

On the one hand, in Italy, the disruption of services acted as one of the major healthcare barrier-renunciation, especially during the first pandemic phases when the main countermeasure adopted was the general lockdown. Numerous studies have assessed the influence of the COVID-19 pandemic on hospital service utilization, revealing a significant reduction in hospital capacities [25–27].

Our data show that living in Centre or South Italy, declaring many economic difficulties, being older than 75, reporting two or more chronic diseases and sensory problems were condition associated with healthcare renunciation due to services disruption.

On the other hand, fear of contagion played a significant role in healthcare renunciation, among women, among those with higher educational levels, individuals experiencing economic difficulties, and residents of Southern Italy [28]. Geographic variation may be attributed to the timing and severity of pandemic waves and the corresponding restrictions, which differed markedly across Italian regions.

Several studies have documented the immediate effects of treatment delays during the COVID-19 pandemic [29, 30] the long-term consequences remain uncertain and necessitate future investigation. For this reason, identifying the profile of people reporting healthcare renunciation could guide policymakers to aim specific actions. Numerous studies demonstrate the greater extent for healthcare renunciation in people with chronic condition, showing reduced use of hospital, emergency department and outpatients during lockdowns and other high-transmission periods [31, 32]. Effects of this behaviour may include, according to the literature, heightened morbidity and adverse health outcomes [33].

Strengths and limitations

Surveillance system enables timely, regional comparisons and precious information to offer crucial insights for health policy by measuring how older adults utilize healthcare services like diagnostic exams and medical visits.

The present study has some limitations. One attributable to the self-reporting nature of data collection. Data cannot be validated with objective measures and collected information could be biased. In any way, self-reported data are valid information useful to monitor events over time [34]. Second, another potential limitation is related to the period of the questions on healthcare renunciation, which may partially precede the COVID-19 emergency for some respondents. A sensitivity analysis restricted to interviews conducted between March and December 2021 showed consistent results supporting the robustness of the findings of the full period analysed (August 2020–December 2021).

In addition, during the pandemic, the surveillance coverage was lower in the Northern regions, which were initially the most affected, such as Lombardy that did not participate in the survey.

Conclusion

This study represents one of the first effort to evaluate the healthcare renunciation in the elderly population across the entire national territory of Italy. The capacity of Surveillance to detect rapidly changes in health dynamics over the population enabled exploration of specific domains and facilitated analysis of the relationship between care renunciation and other pertinent variables during emergency.

Finally, it is important to protect vulnerable groups, particularly older adults with economic or health challenges, and tailoring interventions based on the causes of renunciation—whether fear or service inaccessibility. Strengthening healthcare infrastructure, improving communication, and supporting healthcare professionals with tools like telemedicine are key to building a more equitable and resilient healthcare system. Continuous monitoring is essential to respond to shifting reasons behind care renunciation and to guide effective, inclusive health strategies.

Author contributions

All authors contributed to development of the study design and interpretation of findings. B.C., F.A., V.M., V.PO. and M.M. contributed to data collection and data analysis. D.M., V.PE., M.O.T. and V.PO. undertook the literature search. B.C., D.M., F.A., and V.PE. wrote the manuscript. All authors have reviewed and approved the publication of the final version of this paper.

Conflict of interest: All co-authors declare no conflicts of interest.

Funding

This study did not receive any external financial support.

Data availability

The data underlying this article cannot be shared publicly due to privacy restrictions. The data will be shared on reasonable request to the corresponding author.

Ethics statement

The study was approved by the Ethics Committee of the Istituto Superiore di Sanità (the protocol number of the final opinion is AOO-ISS—11/07/2023-0032688 for PASSI d’Argento).

Key points.

• The collected data from PdA surveillance system showed that a significant portion of the elderly population in Italy reported healthcare renunciation during the COVID-19 pandemic. The primary reasons included fear of COVID-19 infection and service disruptions.

• The present study highlights how the pandemic exacerbated existing health disparities. Elderly individuals with economic difficulties, chronic diseases, and sensory problems were more likely to forgo medical care. This could have significant consequences for morbidity and mortality risk. The renunciation of healthcare services varied across Italy, with higher rates observed in regions with severe pandemic impacts and economic challenges.

• The findings underscore the need for targeted health policy interventions to address healthcare renunciation, especially among vulnerable populations. Ongoing monitoring is essential to adapt strategies and ensure comprehensive healthcare delivery.