The global activity limitation indicator and self-rated health: two complementary predictors of mortality

Impact of neighborhood context on self-rated health among very old adults living in Germany: a cross-sectional representative study

BACKGROUND

Increasingly, evidence has shown that different aspects of neighborhood context play a significant role in self-rated health, one of the key health indicators in advanced age. Nevertheless, very old adults are often under represented or excluded from such research. Therefore, the first aim of this study was to examine whether social, socioeconomic, and physical neighborhood context is associated with self-rated health in the very old population of Germany. The second objective was to explore whether the link of socioeconomic and physical neighborhood context with self-rated health is moderated by availability of social resources in neighborhoods.

METHODS

Data from the representative survey, "Old Age in Germany" (D80+) were employed. In total, the study sample of D80+ included 10,578 individuals aged 80 years and over. Additionally, the D80+ data were matched with the freely accessible regional dataset of the Federal Institute for Research on Building, Urban Affairs, and Spatial Development. Two self-rated items (place attachment and social cohesion) were used to assess social neighborhood context. Socioeconomic context of neighborhoods was operationalized by German index of socioeconomic deprivation. To evaluate physical context, perceived measures of building conditions and walkability were included. Using the maximum likelihood estimator with robust standard errors, logistic regression models were estimated to analyze the relationship between neighborhood context (social, socioeconomic, and physical context, as well as their interactions) and self-rated health.

RESULTS

Including 8,066 participants in the analysis, the findings showed that better condition of residential building, higher walkability, being closely attached to outdoor places, and higher social cohesion were associated with higher chance to report good self-rated health of very old adults. In the adjusted models, the German socioeconomic deprivation index was not related to self-rated health. The effect of socioeconomic and physical neighborhood context on self-rated health did not differ according available neighborhood social resources.

CONCLUSIONS

The results indicate that especially more favorable conditions in social and physical neighborhood context are associated with good self-rated health in the very old population of Germany. Further studies should consider multiple aspects of neighborhood context as well as their interplay when examining the neighborhood impact on self-rated health in older populations.

A growing divide: Trends in social inequalities in healthy longevity in Australia, 2001-20

This study examines two decades of change in social inequalities in life and health expectancy among older adults in Australia, one of the few countries that escaped an economic recession during the global financial crisis. We compare adults aged 45+ across three measures of individual socio-economic position-education, occupation, and household wealth-and use multistate life tables to estimate total life expectancy (TLE) and life expectancy free of limiting long-term illness (LLTI-free LE) based on 20 waves of the Household, Income and Labour Dynamics in Australia Survey (2001-20). Our findings highlight substantial social disparities in both TLE and LLTI-free LE in Australia. Grouping individuals by household wealth shows striking differentials in LLTI-free LE. We observe widening social disparities in healthy longevity over time by all three measures of socio-economic position. This diverging trend in healthy longevity is troubling against the backdrop of widening income and wealth inequalities in Australia.

Predictive value of the Global Activity Limitation Indicator (GALI) on all-cause mortality

OBJECTIVES

The Global Activity Limitation Indicator (GALI) is an instrument that measures long-term overall disability. The objective of this study was to evaluate GALI's predictive value on mortality while examining variations according to sex, age, and educational level.

STUDY DESIGN

Longitudinal study.

METHODS

This longitudinal study was based on 42,991 individuals aged ≥15 years who participated in the 2011-2012 National Health Survey and the 2014 European Health Survey in Spain. These records were linked to mortality data up to December 2021. GALI assessed self-reported functional limitation in the past 6 months and classified individuals into three categories: severely limited, limited but not severely, and not limited. Incidence rate ratios (IRR) were calculated using Poisson regression models, adjusting for sociodemographic, lifestyle, and health status variables.

RESULTS

Compared to individuals with no limitations, those with non-severe limitations had an IRR for mortality of 1.27 (95% CI: 1.16-1.38), and 2.04 (95% CI: 1.81-2.31) in those with severe limitations. Women with severe limitations exhibited a higher IRR (2.32; 95% CI: 1.98-2.71) compared to men (1.73; 95% CI: 1.45-2.08) (P for interaction = 0.005). Individuals <65 years with severe limitations showed a greater association (2.22; 95% CI: 1.58-3.10) than those ≥65 (1.49; 95% CI: 1.32-1.69) (P for interaction <0.001). Among individuals with lower educational attainment, the IRR was 2.08 (95% CI: 1.83-2.37), and 1.87 (95% CI: 1.37-2.56) for the higher education group (P for interaction = 0.017).

CONCLUSIONS

GALI is a robust predictor of all-cause mortality in the general population and subgroups. The association is stronger in women, individuals <65 years, and those with lower educational levels.

The impact of interpersonal reporting heterogeneity on cross-country differences in Healthy Life Years in Europe

BACKGROUND

The European Union has used Healthy Life Years (HLY) as an indicator to monitor the health of its aging populations. Scholarly and popular interest in HLY across countries has grown, particularly regarding the ranking of countries. It is important to note that HLY is based on self-assessments of activity limitations, raising the possibility that it might be influenced by differences in health reporting behaviours between populations, a phenomenon known as differential item functioning (DIF).

METHODS

We estimated DIF-adjusted HLY at age 50 for Belgium, France, Germany, Greece, Italy, the Netherlands, Spain, and Sweden to determine the extent to which differences in HLY might be influenced by reporting heterogeneity across countries. We used anchoring vignettes, taken from the 2004 Survey of Health, Ageing and Retirement in Europe, to estimate DIF-adjusted prevalence rates of activity limitations measured by the Global Activity Limitations Indicator (GALI). The Sullivan method was used to calculate DIF-adjusted HLY.

RESULTS

Changes in HLY before and after adjustment ranged from a 1.20-year decrease for men in Italy to a 1.61-year increase for women in Spain. Adjustment for DIF produced changes in the rankings of the countries by HLY, with upward and downward movements of up to three positions.

CONCLUSION

Our results show that DIF is likely to affect HLY estimates, thereby posing a challenge to the validity of comparisons of HLY across European countries. The findings suggest that HLY should be used to monitor population health status within a country, rather than to make comparisons across countries.

Changes in Health Expectancy for Older Adults in Japan: Results from Two Longitudinal Surveys

BACKGROUND

Although there is evidence of improvements in health expectancy among the Japanese population, existing estimates are based on the prevalence of morbidity taken from cross-sectional survey data.

OBJECTIVES

This study employed a multistate life table approach to compute incidence-based health expectancy measures, namely active and inactive life expectancy (LE), for two longitudinal survey cohorts from 1990 to 2009.

METHODS

This study used data from two longitudinal surveys of older adults in Japan: the National Survey of the Japanese Elderly (1990-1999) and the Nihon University Japanese Longitudinal Study of Aging (1999-2009). We employed the Interpolation of Markov Chains technique to compute the number of years at age 65 years to be spent with and without difficulty in performing activities of daily living (ADLs) or instrumental ADLs.

RESULTS

We documented significant increases in active LE for men and women at age 65 years over the 10-year study period. There were significant changes in total LE for men and in the percentage of active life for women. Inactive LE did not significantly change across the two survey cohorts during the study period.

CONCLUSIONS

Our results show that the health status of older adults in Japan has largely improved over the 10-year study period, with increases in both the duration of life and time spent in an active state. This finding offers evidence of compression of morbidity among older men and women in Japan.

Clustering of unhealthy lifestyle behaviors, self-rated health and disability

The main objective was to identify sociodemographic characteristics of the population at risk for a greater clustering of unhealthy behaviors and to evaluate the association of such clustering with self-rated health status and disability. Data come from the 2017 Spanish National Health Survey with a sample of 21,947 participants of 15 years of age or older. Based on tobacco consumption, risk drinking, unbalanced diet, sedentarism, and body mass index <18.5/≥25 we created two indicators of risk factor clustering: 1) Number of unhealthy behaviors (0-5); and 2) Unhealthy lifestyle index (score: 0-15). Self-rated health was dichotomized into "optimal" and "suboptimal," and disability was classified as "no disability," "mild," and "severe" based on the Global Activity Limitation Index (GALI). We estimated prevalence ratios (PR) adjusted for covariates using generalized linear models using the clustering count variable, and dose-response curves using the unhealthy lifestyle index. Most participants (77.4%) reported 2 or more risk factors, with men, middle-age individuals, and those with low socioeconomic status being more likely to do so. Compared to those with 0-1 risk factors, the PR for suboptimal health was 1.26 (95% CI:1.18-1.34) for those reporting 2-3 factors, reaching 1.43 (95% CI:1.31-1.55) for 4-5 factors. The PR for severe activity limitation was 1.66 (95% CI:1.35-2.03) for those reporting 2-3 factors and 2.06 (95% CI:1.59-2.67) for 4-5 factors. The prevalence of both health indicators increased in a non-linear fashion as the unhealthy lifestyle index score increased, increasing rapidly up to 5 points, slowing down between 5 and 10 points, and plateauing afterwards.

Effectivity of a mHealth intervention for individuals with obesity: a study protocol for a controlled intervention study

BACKGROUND

Obesity is considered an epidemic problem with an increasing number of individuals affected. The physical and psychological complaints associated with obesity point to the importance of implementing effective interventions. Innovative mHealth applications appear to be promising in helping provide a continuous and flexible support during the intervention. Since research on mHealth interventions is still relatively sparse, the main goal of the current study is to assess the effectiveness of an mHealth obesity intervention in terms of weight reduction, health behaviours as well as health-related quality of life. In addition, the study aims to investigate various psychological explicit and implicit processes associated with physical activity behaviour.

METHODS

The study includes quantitative and qualitative methods. Regarding the quantitative methods, the goal is to recruit up to 450 individuals at baseline in different obesity centres across Germany with some of these centres offering an mHealth intervention. All individuals who agree to take part in the mHealth intervention will be assigned to the intervention group, while all other individuals will be assigned to the control group. The mHealth obesity intervention consists of three stays at an obesity centre, with approximately six months between stays during which patients are supported by the digital platform CASPAR. The study includes three measurements with a baseline measurement and two follow-up measurements, one after six months and one after twelve months. To assess the effectiveness of the intervention, body weight, physical activity behaviour, eating behaviour as well as health related quality of life will be assessed. In addition, motivation, intentions, self-efficacy, enjoyment, and habit will be used to assess the psychological processes related with physical activity behaviour. A multivariate analysis of variance with repeated measurement and latent growth curve models will be used to compare the development of the variables within the two groups. In relation to the qualitative methods, interviews with individuals of the intervention group will be conducted to shed light on the applicability, acceptance, and usability of the mHealth intervention.

DISCUSSION

This study may provide a valuable insight into the potential of mHealth obesity interventions and the psychological processes related to physical activity behaviour. Trial registration The trial has been registered with the German Register of Clinical Studies (DRKS) on June 30, 2021 under the registration number: DRKS00024836.

Validity of the Global Activity Limitation Indicator (GALI) to evaluate severity of disability

Our aim was to estimate the validity of the Global Activity Limitation Indicator (GALI) when measuring the severity level of disability. Data came from 153 residents of Spain, who requested an evaluation of their degree of disability. We compared disability classifications (severe vs. non-severe) from GALI against those from the 36-item questionnaire WHODAS 2.0, the current gold standard measure of disability. The sensitivity of GALI to detect severe disability was 58.3% [95% confidence interval (CI):43.2-72.4], and the specificity was 84.8% (95% CI: 76.4-91.0). Thus, the validity of GALI to accurately categorize the degree of severity of an individual's disability is not high, this in great part due to its limited sensitivity.

The impact of population's educational composition on Healthy Life Years: An empirical illustration of 16 European countries

Healthy Life Years (HLY) is a prominent summary indicator for evaluating and comparing the levels of population health status across Europe. Variations in HLY, however, do not necessarily reflect underlying differences in health and mortality levels among countries and the indicator is particularly sensitive when broken down by subpopulations. For instance, despite European countries showing large HLY inequalities by educational level, these countries are also heterogenous regarding their population composition by educational attainment, which most likely affects their HLY levels. We demonstrate how this compositional effect shapes HLY levels by providing estimates for HLY by educational attainment and gender for 16 European countries using the Sullivan method. We use prevalence data about limitations in daily activities from the European Union Statistics on Income and Living Conditions (EU-SILC) and mortality data from the Eurostat database. Finally, we adjust for compositional effects by means of standardization. The education-adjusted HLY estimates do not differ much from conventional HLY. Yet, we find that in some countries HLY levels are indeed affected by the population composition by educational attainment. For example, low-, medium-, and high educated individuals in Portugal show more HLY than their counterparts in Poland. Still, Poland's total HLY value slightly exceeds that of Portugal, indicating favorable health and mortality conditions in Poland. It is Poland's lower relative number of low educated individuals in its population that is responsible for producing this higher total HLY value. We conclude that differentials in HLY due to differences in the relative size of educational subpopulations are generally small in HLY across Europe but they can play an important role for countries that experienced large differences in their educational expansion.

Impact of self-assessed health status and physical and functional limitations on healthcare utilization and mortality among older cancer survivors in US

PURPOSE

The purpose of this study was to examine the impact of physical limitations, functional limitations and self-assessed health status on mortality and healthcare utilization among older cancer survivors.

METHODS

National Medicare Current Beneficiary Survey (MCBS) cost and use data from 2008 to 2013 were used for analysis. Physical limitations, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) were assessed on multiple questions, and self-assessed health was measured on a five-point scale (1-5: Excellent-Poor). Multivariable logistic regression and Poisson regression models were used for hospitalization, re-hospitalization and mortality rates based on three follow up years.

RESULTS

This study included 17,715 cancer patients with a mean age of 75 years and 57% females. Cancer survivors with poor self-assessed health had a higher rate of hospitalizations (adjusted Odds Ratio: aOR: 1.60, 95% Confidence Interval: CI: 1.47-1.72, p < 0.001) relative to non-cancer participants. Compared to participants with no history of cancer, cancer survivors with IADL (aOR: 1.41, 95% CI: 1.25-1.58, p < 0.001) or with poor self-assessed health (aOR: 1.39, 95% CI: 1.21-1.60, p < 0.001) were more likely to have a higher number of hospital readmissions within 30 days of a prior hospitalization. Three-year mortality rate was significantly higher among cancer survivors with poor self-assessed health (Hazard Ratio: 2.81, 95% CI: 2.81-2.82, p < 0.001).

CONCLUSION

Self-assessed health and physical and functional limitations significantly and independently impact healthcare utilization and mortality among older cancer survivors. Healthcare providers should incorporate formal assessments of both self-assessed health and functional status among older cancer survivors in their clinical practice.

IMPLICATION FOR CANCER SURVIVORS

Self-reported health status is a valuable and independent predictor of healthcare utilization and mortality among cancer survivors.

Effects of a web-based rehabilitation aftercare on subjective health, work ability and motivation: a partially randomized controlled trial

Background

Rehabilitation is seen as crucial in dealing with the demographic change in many European countries. In Germany, for example, after having stayed in a rehabilitation center, patients have the possibility to participate in aftercare programs aimed at promoting long-term health behaviour. Despite the relevance of follow-up support for patients’ long-term health and work ability, participation rates in aftercare programs are quite low. Here, web-based aftercare programs can be a viable alternative to the traditional face-to-face programs due to their flexibility in time and location. This research project aims to use quantitative and qualitative methods to gain more insight into the potential of web-based aftercare programs.

Methods

The goal is to recruit up to 1150 patients at baseline in five rehabilitation centers across Germany. For ethical reasons, partially randomized experimental study design is used to quantitatively assess the effectiveness of web-based aftercare programs. All patients are offered the traditional face-to-face aftercare treatment (IRENA). When patients deny to participate in traditional face-to-face aftercare, they are randomly distributed into either web-based aftercare (digIRENA) or a control group. In all three groups, the SF-12, which measures subjective health, and the WAI, which measures working ability, will be used at baseline, 13 weeks, 26 weeks and 43 weeks after the patients have left the rehabilitation center. BREQ-2, which measures motivation, is used only in the traditional aftercare group and the web-based aftercare group. A multivariate analysis of variance with repeated measurement and latent growth curve models will be used to compare the development of the variables in the three groups. For the qualitative part of the study, interviews with patients and therapists will be conducted to shed light on the applicability, acceptance, and usability of web-based aftercare programs.

Discussion

This study may provide valuable insight into the potential of web-based rehabilitation aftercare programs as a way to supplement traditional face-to-face programs. This seems particularly promising if it can manage to reach those patients who do not currently participate in traditional face-to-face rehabilitation aftercare programs due to time and location constraints.

Trial registration

The trial has been registered at the German Register of Clinical Studies (DRKS) with the registration number: DRKS00022467.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04239-z.

Association between Dental Treatment, Quality of Life, and Activity Limitation According to Masticatory Discomfort: Evidence from the Korean National Health and Nutrition Examination Survey (2013-2015)

People with masticatory discomfort are unable to consume a balanced diet, which impacts their general health. We studied the relationship between quality of life and dental care associated with masticatory discomfort. Data from Korea’s representative 6th Korea National Health and Nutrition Examination Survey (KNHANES) were used. Complex sampling analysis with the stratification variable, clustering variable, and weight was applied. Demographic and dental treatment characteristics and activity limitations were compared through chi-square tests. The comparison of quality of life according to masticatory discomfort was performed using linear regression. The risk of masticatory discomfort was high in people who did not undergo regular oral examinations and preventive and definitive caries treatment and in those who received periodontal, surgical, endodontic, or prosthetic treatments. Generally, people with masticatory discomfort engaged in less activity owing to other disorders like arthritis, rheumatism, and back, neck, and oral disease. People with masticatory discomfort scored low on quality of life. People who received regular oral examinations and preventive care had a low level of masticatory discomfort, and the treated persons had high masticatory discomfort. Therefore, in order to reduce masticatory discomfort, more diverse and active care should be provided for prevention, specifically regular oral examinations.

Health-related predictors of cancer registry-notified cancer of unknown primary site (CUP)

BACKGROUND

The relationship between comorbid disease and health service use and risk of cancer of unknown primary site (CUP) is uncertain.

METHODS

A prospective cohort of 266,724 people aged 45 years and over in New South Wales, Australia. Baseline questionnaire data were linked to cancer registration, health service records 4-27 months prior to diagnosis, and mortality data. We compared individuals with incident registry-notified CUP (n = 327; 90% C80) to two sets of randomly selected controls (3:1): (i) incident metastatic cancer of known primary site (n = 977) and (ii) general cohort population (n = 981). We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

In fully adjusted models incorporating sociodemographic and lifestyle factors, people with cancer registry-notified CUP were more likely to have fair compared with excellent self-rated overall health (OR 1.78, 95% CI 1.01-3.14) and less likely to self-report anxiety (OR 0.48, 95% CI 0.24-0.97) than those registered with metastatic cancer of known primary. Compared to general cohort population controls, people registered with CUP were more likely to have poor rather than excellent self-rated overall health (OR 6.22, 95% CI 1.35-28.6), less likely to self-report anxiety (OR 0.28, 95% CI 0.12-0.63), and more likely to have a history of diabetes (OR 1.89, 95% CI 1.15-3.10) or cancer (OR 1.62, 95% CI 1.03-2.57). Neither tertiary nor community-based health service use independently predicted CUP risk.

CONCLUSION

Low self-rated health may be a flag for undiagnosed cancer, and an investigation of its clinical utility in primary care appears warranted.

Contribution of chronic conditions to disability in men and women in France

Background

Women report more disability than men perhaps due to gender differences in the prevalence of diseases and/or in their disabling impact. We compare the contribution of chronic diseases to disability in men and women in France, using a disability survey conducted in both private households and institutions, and we also examine the effect of excluding the institutionalized population.

Methods

Data comprised 17 549 individuals age 50+, who participated in the 2008-09 French Disability Health Survey including people living in institutions. Disability was defined by limitations in activities people usually do due to health problems (global activity limitation indicator). Additive regression models were fitted separately by gender to estimate the contribution of conditions to disability taking into account multi-morbidity.

Results

Musculoskeletal diseases caused most disability for both men (10.1%, CI: 8.1-12.0) and women (16.0%, CI 13.6-18.2). The second contributor for men was heart diseases (5.7%, CI: 4.5-6.9%), and for women anxiety-depression (4.0, CI 3.1-5.0%) closely followed by heart diseases (3.8%, CI 2.9-4.7%). Women's higher contribution of musculoskeletal diseases reflected their higher prevalence and disabling impact; women's higher contribution of anxiety-depression and lower contributions of heart diseases reflected gender differences in prevalence. Excluding the institutionalized population did not change the overall conclusions.

Conclusions

The largest contributors to the higher disability of women than men are moderately disabling conditions with a high prevalence. Whereas traditional disabling conditions such as musculoskeletal diseases are more prevalent and disabling in women, fatal diseases such as cardiovascular disease are also important contributors in women and men.

Health, education and employment status of Europeans aged 60 to 69 years: results from SHARE Survey

The objective of this study was to identify health and education related predictors of employment/self-employment in the age between 60 and 69 yr in Europe. Data were obtained from Survey of Health, Ageing and Retirement in Europe (SHARE) study-Wave 6. Our final sample (n=13,447) was retrieved from 16 European Union member states, Switzerland and Israel. We used logistic regression model including education level, physical and mental health parameters to predict employment/self-employment vs. retired. Employment/self-employment was associated with higher education status, increased risk for depression, and obesity, but with decreased risk for chronic diseases, loneliness and limitations in daily life activities. Age-appropriate working conditions, part-time options, and enhanced job characteristics may contribute to maintain a good health status and prevent negative aspects of work that can induce the risk for stress and depression.

The subjective health of adults in Germany

The term 'subjective health' reflects not only existing illnesses and health complaints, but particularly emphasizes the personal well-being. Studies often collect data on subjective health by asking participants to provide self-assessments of their general state of health. This was also the case with GEDA 2014/2015-EHIS, which employed the internationally renowned Minimum European Health Module (MEHM) as part of the study. Its results demonstrate that 68.2% of adults in Germany rate their general health as very good or good, with the remaining 31.8% rating it as fair, poor or very poor. The proportion of women who rate their general health as very good or good is slightly lower than the proportion of men who do so (66.6% compared to 69.9%). With increasing age, women and men view the condition of their general health as worsening. The study also identified educational differences which showed that men and women with low levels of education tend to rate their health worse compared to self-assessments provided by women and men with higher levels of education, and in some cases also regional differences.

Measuring disability: a systematic review of the validity and reliability of the Global Activity Limitations Indicator (GALI)

Background

GALI or Global Activity Limitation Indicator is a global survey instrument measuring participation restriction. GALI is the measure underlying the European indicator Healthy Life Years (HLY). Gali has a substantial policy use within the EU and its Member States. The objective of current paper is to bring together what is known from published manuscripts on the validity and the reliability of GALI.

Methods

Following the PRISMA guidelines, two search strategies (PUBMED, Google Scholar) were combined to identify manuscripts published in English with publication date 2000 or beyond. Articles were classified as reliability studies, concurrent or predictive validity studies, in national or international populations.

Results

Four cross-sectional studies (of which 2 international) studied how GALI relates to other health measures (concurrent validity). A dose-response effect by GALI severity level on the association with the other health status measures was observed in the national studies. The 2 international studies (SHARE, EHIS) concluded that the odds of reporting participation restriction was higher in subjects with self-reported or observed functional limitations. In SHARE, the size of the Odds Ratio’s (ORs) in the different countries was homogeneous, while in EHIS the size of the ORs varied more strongly. For the predictive validity, subjects were followed over time (4 studies of which one international). GALI proved, both in national and international data, to be a consistent predictor of future health outcomes both in terms of mortality and health care expenditure. As predictors of mortality, the two distinct health concepts, self-rated health and GALI, acted independently and complementary of each other. The one reliability study identified reported a sufficient reliability of GALI.

Conclusion

GALI as inclusive one question instrument fits all conceptual characteristics specified for a global measure on participation restriction. In none of the studies, included in the review, there was evidence of a failing validity. The review shows that GALI has a good and sufficient concurrent and predictive validity, and reliability.

Economic Hardship and Educational Differentials in Disability in 26 European Countries

OBJECTIVE

The objective of this article is to study to what extent European variations in differentials in disability by education level are associated to variation in poverty.

METHOD

Using the European Statistics on Income and Living Conditions (EU-SILC) for 26 countries, we measure the prevalence of activity limitation (AL) and the rate of economic hardship (EH) by level of education. We measure the increased AL prevalence (disadvantage) of the low-educated relative to the middle-educated and the reduced AL prevalence (advantage) of the high-educated groups, controlling or not for EH.

RESULTS

The rate of EH and the extent of the AL-advantage/disadvantage vary substantially across Europe. EH contributes to the AL-advantage/disadvantage but to different extent depending on its level across educational groups.

DISCUSSION

Associations between poverty, education, and disability are complex. In general, large EH goes along with increased disability differentials. Actions to reduce poverty are needed in Europe to reduce the levels and differentials in disability.

Impact of Question Wording on the Measurement of Activity Limitation: Evidence From a Randomized Test in France

OBJECTIVE

The Global Activity Limitation Indicator (GALI), a single question measuring disability, had been introduced in various European surveys since 2004. The complexity of its wording has been questioned. Our study compares alternative variants aiming to simplify the wording.

METHOD

We used the Health-Related Opinion Survey run in 2014 in France (N = 3,009). Its split sample design allows testing four variants of the questions. We analyzed the prevalence of activity limitation (AL) resulting from the four different constructs of the GALI using multinomial logistic regressions, adjusted for background variables and functional limitations (FLs).

RESULTS

The alternative GALI variants result in significantly different prevalences compared with the original question, in particular for people with FL. The current variant is more inclusive than the routed variants.

DISCUSSION

Our study suggests limited benefits of changing the GALI construct which do not outweigh the costs of breaking the established chronological series of the current variant.

Excess mortality following hip fracture: impact of self-perceived health, smoking, and body mass index. A NOREPOS study

Self-perceived health, smoking, and body mass index measured years before the hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than subjects who did not fracture.

INTRODUCTION

This study aimed to investigate the impact of pre-fracture self-perceived health, smoking, and body mass index (BMI) on excess post-hip fracture mortality using matched peers without hip fracture as reference.

METHODS

The study was based on the Cohort of Norway (CONOR) consisting of 10 regional health studies (1994-2003) and the NOREPOS hip fracture database (1994-2008). A matched cohort design was used to compare survival between hip fracture patients and subjects without fracture (matched on gender, age at participation in CONOR, and study site). Subjects aged ≥60 years were included. Hazard ratios were estimated using stratified Cox regression. Age-standardized mortality was also calculated.

RESULTS

Overall, hip fracture patients (N = 3177) had a 2.26-fold (95 % CI 2.13, 2.40) increased mortality compared to matched subjects (N = 20,282). The highest excess mortality was found in hip fracture patients reporting poor health (HR 4.08, 95 % CI 3.17, 5.26) and daily smoking (HR 3.25, 95 % CI 2.89, 3.66) and in patients with BMI <18.5 (HR 3.07, 95 % CI 2.11, 4.47) prior to the fracture. However, excess mortality was also observed in hip fracture patients in all other categories of BMI, self-perceived health, and smoking.

CONCLUSIONS

Information on self-perceived health, smoking, and BMI collected years before hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than the matched subjects who did not fracture. This suggests that both pre-fracture health status and factors related to the hip fracture itself might affect post-hip fracture mortality.

Harmonising summary measures of population health using global survey instruments

Summary measures of population health—health expectancies in particular—have become a standard for quantifying and monitoring population health. To date, cross-national comparability of health expectancies is limited, except within the European Union (EU). To advance international comparability, the European Joint Action on Healthy Life Years (JA: EHLEIS) set up an international working group. The working group discussed the conceptual basis of summary measures of population health and made suggestions for the development of comparable health expectancies to be used across the EU and Organisation for Economic Co-operation and Development (OECD) members. In this paper, which summarises the main results, we argue that harmonised health data needed for health expectancy calculation can best be obtained from ‘global’ survey measures, which provide a snapshot of the health situation using 1 or a few survey questions. We claim that 2 global measures of health should be pursued for their high policy relevance: a global measure of participation restriction and a global measure of functional limitation. We finally provide a blueprint for the future development and implementation of the 2 global measures. The blueprint sets the basis for subsequent international collaboration, having as a core group Member States of the EU, the USA and Japan. Other countries, in particular OECD members, are invited to join the initiative.

The joint association of self-rated health and diabetes status on 14-year mortality in elderly men and women

PURPOSE

Low self-rated health (SRH) has been found to be associated with increased risk of type 2 diabetes (T2D) and with mortality. We examined the possible interaction between SRH and diabetic state on all-cause mortality in a large cohort of elderly subjects, followed for 14 years.

METHODS

During the years 2000-2004, survivors of the nationwide longitudinal Israel Study of Glucose Intolerance, Obesity and Hypertension were interviewed and examined for the third follow-up. The 1037 participants (mean age 72.4 ± 7.2 years) were asked to rate their health as: excellent, good, fair, poor, or very poor. Glucose categories were as follows: Normoglycemic, Prediabetes, T2D and Undiagnosed diabetes. Survival time was defined as the time from interview to date of death or date of last vital status follow-up (August 1, 2013). Multivariate Cox proportional hazards models were performed in order to assess whether SRH interacts with glycemic state in the association with mortality.

RESULTS

A better SRH was reported by those with undiagnosed than known diabetes, and best for normoglycemic and prediabetic individuals. While all individuals with fair or poor/very poor SRH were at increased risk of mortality compared to those with excellent/good SRH, in the known diabetic individuals a greater hazard was observed in the excellent/good SRH (HR 3.32, 95 % CI 1.71-6.47) than in those with fair or poor/very poor SRH (HR 2.19, 95 % CI 1.25-3.86), after adjusting for age, sex, ethnic origin, marital status, education, BMI, physical activity, CVD, tumors, and creatinine level (p for interaction = 0.01).

CONCLUSIONS

Self-rated health is not a sensitive tool for predicting mortality in elderly men and women with known T2D.

Local area unemployment, individual health and workforce exit: ONS Longitudinal Study

Background: In many developed countries, associations have been documented between higher levels of area unemployment and workforce exit, mainly for disability pension receipt. Health of individuals is assumed to be the primary driver of this relationship, but no study has examined whether health explains or modifies this relationship. Methods: We used data from 98 756 Office for National Statistics Longitudinal Study members who were aged 40–69 and working in 2001, to assess whether their odds of identifying as sick/disabled or retired in 2011 differed by local authority area unemployment in 2001, change in local area unemployment from 2001 to 2011 and individual reported health in 2001 (self-rated and limiting long-term illness). Results: Higher local area unemployment and worse self-rated health measures in 2001 were independently related to likelihood of identifying as sick-disabled or retired, compared to being in work, 10 years later, after adjusting for socio-demographic covariates. Associations for local area unemployment were stronger for likelihood of identification as sick/disabled compared to retired in 2011. Associations for changes in local area unemployment from 2001 to 2011 were only apparent for likelihood of identifying as retired. For respondents that identified as sick/disabled in 2011, effects of local area unemployment in 2001 were stronger for respondents who had better self-rated health in 2001. Conclusions: Strategies to retain older workers may be most effective if targeted toward areas of high unemployment. For persons in ill health, local area unemployment interventions alone will not be as efficient in reducing their exit from the workforce.

Does retirement (really) lead to worse health among European men and women across all educational levels?

OBJECTIVES

Whereas the view that retirement would have negative effects on health is widespread, many existing studies may be biased because they do not sufficiently take into account the issue of reverse causation. Using a large longitudinal dataset for twelve Western European countries, this study uses an instrumental variables approach to assess effects of retirement on health.

METHODS

Longitudinal data for the years 2009-2012 for 75,722 men and 63,911 women from twelve Western European countries are derived from the European Union Statistics on Income and Living Conditions. Health outcomes used in this study are self-rated health, activity limitations and chronic conditions. Country- and sex-specific early- and full-pension ages are used as instruments. Models were stratified by sex as well as educational levels to assess potential effect heterogeneity.

RESULTS

Results obtained from conventional random-effects models suggest that retired men and women have higher chances of reporting bad self-rated health, activity limitations as well as chronic conditions. However, using an instrumental variables (IV) approach the results suggest that retirement can lead to health improvements in self-reported health as well as activity limitations among men and women. The health improvements associated with retirement among men and women exist across all educational levels.

DISCUSSION

Contrary to several previous studies, the results suggest that retirement may have health preserving effects. The positive effects of retirement and health exist for low as well as high educated men and women.