Background

Informal caregivers providing assistance to older adults living in Italy’s Inner Areas face compounded challenges in accessing healthcare [1, 2]. To support policy development aligned with AGE-IT SPOKE 5 (WP4), we developed a simulation framework revealing spatial inequalities and care dynamics. While spatial analysis methods offer valuable insights into the distribution of healthcare services and demographic patterns, an Agent-Based Model (ABM) can complement these by simulating heterogeneous elderly and caregiver agents with diverse mobility, income levels, and care needs. This study focuses on the case of Premeno (VB), which has 763 inhabitants and an ageing index of 274.4¹, it is classified in SNAI band C², among the “belt” municipalities having population density of fewer than 5,000 inhabitants³. The model serves as a decision-support tool for local administrators, helping them evaluate trade-offs between efficiency and patient-centered care.

Methods

We built an ABM and simulation platform (NetLogo) [3] representing older adult–caregiver dyads in Premeno (VB). Through multimodal data integration, this study combines multiple heterogeneous sources, formats, and data modalities—including demographic datasets, GIS (Geographical Information Systems) layers, drone-acquired remote sensing data, surveys, and structured interviews—to generate insights otherwise unavailable. Specifically, structured interviews provide systematic qualitative data that enrich the interpretation of quantitative datasets, allowing census data to reveal aggregate patterns at the national level while interviews explain local-level processes [4]. The structured interviews, conducted with a selected group of informal caregivers, aimed to gather their perspectives on three key areas: accessibility of local services, mobility, and the level of caregiving effort. Multimodal-data-informed agents interact with healthcare and support service points under geographic and caregiver resource constraints, realistically reproducing the spatial dynamics of service accessibility and informal caregiving. We compute two core indices to identify spatial and social disparities in long-term care accessibility: a walkability index, representing physical access to care and support for healthy ageing, and a caregiver effort index, reflecting the multidimensional burden of caregiving.

Results

The simulation compares a real-world baseline with alternative facility configurations—such as differently localized or augmented facility networks—to evaluate potential outcomes for stakeholders. In Premeno (VB), the evidence-based assessment of service relocation, carried out through a comparative analysis of existing and proposed pedestrian routes, reveals significant improvements in elevation change, safety, travel time, and overall accessibility.

Implications

The tool supports policy-making by identifying underserved areas and enabling the territorial customization of care models. Its outputs align with key objectives of AGE-IT, including long-term care monitoring (Result 2), resource mapping (Result 3), and support network planning (Result 4). Simulation results demonstrate measurable improvements in equity and sustainability across alternative configurations, showing that the spatial rearrangement of service points significantly influences caregiver effort and older adults’ accessibility. Additionally, the model contributes to assessments of ageing-in-place feasibility and fosters innovation in digital care strategies.

References

1. Albertini, M. and Prandini R., Care inequality in later life in ageing societies : The unequal distribution of the intensity of informal support in Europe, in The Routledge Handbook of Contemporary Inequalities and the Life Course. 2021, Routledge: New York, NY, USA. p. 274–284.

2. Tomassini, C., Albertini, M. and Lallo C., Avanzare insieme nella società anziana: Considerazioni multidisciplinari sulla domanda di assistenza agli anziani in Italia. 2024, Italy: Società editrice il Mulino.

3. Bandini, S., Manzoni S. and Vizzari, G., Agent Based Modeling and Simulation: An Informatics Perspective. JASSS, 2009.

4. Garrone, R., Nishinari, K. and Bandini, S., Fostering sustainable walkability in remote areas: integrating territorial data sources and AI-based simulation techniques, in 2024 IEEE International Conference on Big Data (BigData). IEEE. p. 15–18.


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1 https://ottomilacensus.istat.it/comune/103/103055/

2 The SNAI classification - “Strategia Nazionale Aree Interne”, provides that “belt” municipalities are those located, on the basis of an accessibility indicator calculated in terms of minutes of road travel, up to a maximum of 27.7 minutes from the nearest service hub.

3 L. 158/2017, Realacci

The Italian National Strategy for Inner Areas (SNAI) represents a key innovation in European cohesion policy, targeting regions affected by depopulation, service deprivation, and economic decline. Covering nearly 60% of Italy's territory and home to about a quarter of the population, Inner Areas are identified based on their driving distance from essential services—schools, hospitals, and transport hubs. This study proposes a refinement of the SNAI approach by disaggregating these services and calculating real-time driving distances for each municipality using OpenStreetMap and TomTom data. Three separate indicators—proximity to high schools, train stations (silver category or higher), and hospitals with emergency departments—are used to classify municipalities according to SNAI's own distance thresholds. Results show significant variation in accessibility: only 10% of municipalities are classified as inner areas considering their distance from schools, compared to 35% for train stations and 43% for hospitals. Given the particularly critical situation in healthcare access, we examine the potential impact of planned community-based facilities under Italy’s National Recovery and Resilience Plan (NRRP). Incorporating these new structures reduces the share of health-related inner areas to 7.7% and average travel times to 15 minutes. While promising, these findings depend on the timely and effective implementation of NRRP investments.

This study focuses on the analysis of walkability as a factor in promoting services accessibility within Italian inner areas, presenting the municipality of Premeno (VB, ITALY) as a case study. While walkability is well-studied in urban contexts, often associated with socially inclusive and sustainable communities, its application in rural and remote territories remains limited, despite growing interest driven by demographic changes, such as aging populations and depopulation.

The study investigates the use of Geographic Information Systems (GIS) and thematic mapping to assess access to local public services, with attention to older adults with reduced mobility (30% of the entire population - about 700 inhabitants). Through data representation by GIS, the spatial analysis allowed evaluating current pedestrian access to municipal offices and medical facilities (analysis lab), and assessing the benefits of relocating such services to a more accessible site from Via Roma to Villa Bernocchi, the second one offering demonstrably improved accessibility for both older adults and their informal caregivers (parents, neighbors and friends).

The evaluation includes key walkability indicators (distance, elevation, safety, infrastructure quality, lighting, barrier-free access), showing that the proposed relocation offers significantly improved accessibility, enhancing the usability of services for the entire community. The study underscores the value of integrating territorial data into planning processes, supporting evidence-based decisions that promote equity, inclusion, and autonomy in marginal areas.. It lays the groundwork for future efforts to develop custom walkability indices adapted to the geographical and demographic specificities of inner areas.

As in physics, distances in demography are not flat, but curve around points of mass. While socio-economic evolution and technological progress have decreased travel times between large national and international metropolitan centres, they have also reduced the time deemed acceptable for a single trip in relation to the physical distance travelled and the purpose of the journey (e.g. health, education, work or leisure). Local communities unable to ensure such ever-shrinking connection times with the rest of the national urban network risk increasingly “curving” the space around them. They will appear more and more distant, to the point of being considered unreachable, and will disappear from the national socio-economic and public service horizon. These communities are at risk of becoming demographic “black holes”, disappearing from the lives of neighbouring and national communities, which has worrying implications for the protection of constitutionally recognised rights. This study proposes a prototype indicator, the W-MCFI, to identify potential black holes with respect to the care needs of older dependent people. The W-MCFI uses data from the ISTAT “Inner Areas” indicator (distance), data on the demographic structure of municipal communities (points of mass) and data on the health status of older people (needs). These data have been combined to create a “compensatory” specific composite index.

Informal caregiving in later life in Italian inner areas offers a valuable lens to explore the interdependence of territorial context, social relationships, and the digitalisation of healthcare and social care services. Despite increasing interest in research and policy, older informal caregivers constitute a hidden, hard-to-reach population, digital infrastructures are unevenly distributed, and the territorial dimension remains underexplored. Against this background, this study explores the experiences of older informal caregivers in the Lanzo Valley, a mountainous inner area in north-western Italy. It examines which healthcare and social care services they use, the barriers and facilitators they encounter, and the risks and opportunities they perceive regarding service digitalisation. Adopting an observational, qualitative, cross-sectional, descriptive design, 20 semi-structured interviews were conducted, transcribed verbatim, and analysed thematically. Findings show that this territorial context shapes social relationships, as well as formal care delivery and informal caregiving practices, supporting a place-based approach. Furthermore, drawing on the theory of sense of community, a sense of belonging and attachment to place among older informal caregivers emerge as key resources, with social cohesion being experienced as an everyday reality and acting as a buffer against social isolation. Finally, building on the digital care infrastructure critical perspective, despite limited access to formal digital services, older informal caregivers develop informal strategies to access, search, and share information. This study shows how these bottom-up strategies sustain informal caregiving in the inner area. Policies should build on such strategies, integrating them into broader community-building interventions to strengthen local social cohesion and social inclusion.

This study investigates the evolution of population aging in Italy, with a specific focus on the spatial dimensions of the phenomenon, adopting a diachronic and multi-scalar analytical framework. The reference period spans from 1991 to 2021, drawing on data provided by Istat, including traditional censuses (up to 2011), the permanent census (2021) and official population projections (up to 2043). The analysis centers on two interrelated dimensions: the disparities of aging across multiple territorial scales, and its local (spatial) dimension. To address the former, a two-stage nested Theil decomposition is employed to quantify spatial inequalities across macro-regions, regions, provinces, and municipalities. To examine the latter, techniques of local spatial autocorrelation are applied to identify clustering patterns and their temporal trajectories. Findings reveal a progressive reduction in multi-scalar disparities in the distribution of the elderly population, with growing significance attributed to intra-provincial dynamics (i.e. between municipalities, local scale). At the same time, the analysis of local spatial patterns highlights a notable persistence: despite widespread population aging over the three decades considered, the territorial configurations of the phenomenon have remained substantially stable. This apparent paradox—marked by increasing spatial homogenization alongside the resilience of local structures—warrants further reflection on the complex and layered geography of demographic aging.

When demographic ageing is challenging for Western societies, it is even more so for smaller municipalities in rural or internal areas, which characterise most Italian territory. Smaller municipalities in remote areas (“internal areas”) are more affected because they are where older people concentrate most and are most difficult to reach and provide public services to. Further, family resources, the primary care providing source, are scarcer in rural areas due to the younger population’s outmigration to cities.

We examine the strategies adopted during the ageing process in two municipalities of the mountainous context of the Val di Susa (Piedmont, Italy). Meana di Susa comprises 21 small housing agglomerates with a restaurant, a pharmacy and a shop, but no clear central gathering point. Mattie is a comparable neighbouring municipality with a proper centre, a few bars, a local transport service, and more active associationism organising activities for its population. We analyse 52 in-depth interviews with older residents (aged 65+) of the two municipalities along the ageing process, focusing on their ageing models and care convoys (Kahn & Antonucci 1980; Kemp et al. 2013) to depict the specific care strategies put in place in the present and envisaged for the future.

Preliminary results highlight how the rural mountainous environment shapes ageing through life experiences, institutional expectations and perspectives, while family-related and health events structure biographical narratives and the availability of resources. The physical environment and the historical development of the community are strongly reflected and incorporated into individuals’ perceived (lack of) agency with respect to growing older and progressively more isolated.

This study analyzes systemic depopulation in Italian and Austrian municipalities (2001-2023) using ARIMA modeling to distinguish structural demographic decline from demographic fluctuations due to cyclical and erratic effects. Italy and Austria present very heterogeneous pictures of systemic depopulation; in particular, the phenomenon affects Austria very marginally (68 out of 2114 municipalities, or 3.2% of the total) and Italy more acutely (1117 out of 7896 municipalities, or 14.1% of the total). A common trait lies in the fact that, in both countries, the municipalities affected by systemic depopulation (Systemic Depopulation Areas - SyDAs) are inner areas. In Italy, 87.01 percent of SyDAs municipalities are in inner areas; the percentage rises to 94% in Austria (64 out of 68). Statistical tests confirm the presence of a statistically significant association between inner area status and systemic depopulation (for both countries, p-values are less than 0.05); however, the association has different levels of variability and magnitude between the two countries (Italy: odds ratio=9.17 and 95% CI= 7.68 - 11.03; Austria: odds ratio= 3.02 and 95% CI= 1.23-10.19). Despite these results, it should be noted that Italy still has a substantial minority of SyDAs municipalities in central and non-inner areas (145 out of 1117, about 13% of the total). Overall, the results demonstrate ARIMA's effectiveness in identifying structural demographic decline and reveal inner areas' specific vulnerability to this phenomenon. Such evidence also clarifies the usefulness of multidimensional analytical approaches to more precisely target policy interventions.