Educational Attainment and Later-Life Cognitive Function in High- and Middle-Income Countries: Evidence From the Harmonized Cognitive Assessment Protocol

OBJECTIVES

Identifying social policies that can promote cognitive health is crucial for reducing the global burden of dementia. We evaluated the importance of educational attainment for later-life cognitive function in various social and geographic settings.

METHODS

Using harmonized data for individuals aged ≥65 years from the United States Health and Retirement Study (HRS) and its international partner studies in England, Mexico, China, and India, and each study's respective Harmonized Cognitive Assessment Protocol (HCAP), we conducted a cross-national comparative study to examine the role of educational attainment in later-life cognitive function across countries (n = 14,980, 2016-2019). We used multivariable-adjusted regression to estimate associations between educational attainment and harmonized global cognitive function scores.

RESULTS

In Mexico, China, and India, the general cognitive function scores on average are approximately one standard deviation of the HRS-HCAP cognitive function score distribution lower compared to the United States and England, paralleling patterns of educational attainment across countries. In all countries, higher educational attainment was associated with progressively higher later-life cognitive function scores. Population-level differences in educational attainment explained about 50%-90% of the observed differences in cognitive function scores across countries.

DISCUSSION

The relationship between education and later-life cognitive function across social and geographic contexts underscores the crucial role of education to promote cognitive health and reduce dementia risk. Continual improvement of educational attainment in low- and middle-income settings may yield a significant pay-off in later-life cognitive health.

A Cross-National Comparison of Biosimilars Pricing in Argentina, Australia, Brazil, and Italy

BACKGROUND

Biosimilar medicines are defined as biological products highly similar to an already licensed biological product (RP). The market entry of biosimilars is expected to reduce the costs of biological treatments.

OBJECTIVE

This study aims to evaluate the range of differences between the prices of biosimilars and the corresponding RP for biologicals approved in four countries.

METHOD

This is a cross-national comparison of pricing of biosimilars in Argentina, Australia, Brazil, and Italy. The study examined online price databases provided by the national authorities of the investigated countries. Biosimilar price difference was calculated by subtracting the unit price of the biosimilar by the unit price of the RP, and then dividing it by the unit price of the RP. The results were presented as percentage.

RESULTS

Brazil had the highest median price reduction (- 36.3%) in biosimilars price, followed by Italy (- 20.0%) and Argentina (- 18.6%). All the biosimilars in Italy were priced below the RP presenting a minimum reduction of 6.3%, while in Australia, most of the prices of biosimilars were equal to the RP. In Argentina, one infliximab-biosimilar displayed price above the RP (40.7%) while the lower priced brand had a reduction of 14.4%. Brazil had four biosimilars with prices above the respective RP, including isophane insulin (1), insulin glargine (1) and somatropin (2).

CONCLUSION

The study revealed a marked dispersion in the price's differences between biosimilars and RP across the studied countries. Governments should evaluate whether their policies have been successful in improving affordability of biological therapies.

What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland

PURPOSE

Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries.

DESIGN/METHODOLOGY/APPROACH

This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries.

FINDINGS

The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries.

ORIGINALITY/VALUE

Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

Inequalities in Mortality in the Asia-Pacific: A Cross-National Comparison of Socioeconomic Gradients

OBJECTIVES

Social inequalities in mortality are poorly studied in much of the Asia-Pacific. Using data from harmonized nationally representative longitudinal health and aging surveys our study systematically assesses mortality disparities across 3 standardized measures of socioeconomic status in 7 Asia-Pacific countries.

METHODS

We used data from multiple waves of 7 representative sample surveys: the Health, Income and Labour Dynamics in Australia survey, China Health and Retirement Longitudinal Study, the Indonesian Family Life Survey, the New Zealand Health, Work and Retirement survey, the Korean Longitudinal Study on Ageing and the Health, Aging and Retirement in Thailand survey, and the Japanese Study of Aging and Retirement. We use Cox proportional hazards modeling to examine how the hazard of mortality differs across domains of social stratification including educational attainment, wealth, and occupational status across countries.

RESULTS

We found consistent and pervasive gradients in mortality risk in the high-income countries by all available measures of social stratification. In contrast, patterns of inequality in adult mortality in middle-income and recently transitioned high-income countries investigated varied depending on the measure of social stratification, with strong gradients by wealth but mixed gradients by education.

DISCUSSION

Analyzing social gradients in mortality in the Asia-Pacific shows that inequalities, especially wealth-based inequalities, in later-life health are present across the region, and that the magnitude of social gradients in mortality is overall larger in high-income countries as compared to middle-income countries.

Cross-national analysis of the prevalence of prolonged grief disorder

BACKGROUND

Prolonged grief disorder (PGD) is now included as a diagnosis in international classification systems. Most research on PGD is based on Western populations, but first data from non-Western countries have recently become available. Little is still known about country-related effects on PGD's prevalence.

OBJECTIVE

Determining possible causes of variations in the prevalence of PGD as defined by DSM-5-TR and ICD-11 within and between countries.

METHODS

We retrieved data from 24 prevalence studies, the World Bank and the 2022 World Risk Report. Negative binomial regressions were used to explore methodological, loss-related and country context characteristics as predictors of PGD. The average rate of PGD was calculated using random effects models.

RESULTS

The included studies comprised 34 samples from 16 countries (20,347 participants). Non-probability sampling and older mean age of the sample as well as lower country vulnerability were associated with higher PGD rates. The average PGD prevalence was 13 % (95 % CI [11, 22]), varying from 5 % (95 % CI [3, 11]) in probability to 16 % (95 % CI [13, 25]) in non-probability samples.

LIMITATIONS

Samples from Europe and North America were overrepresented. For about half of the countries, data were available from only one sample.

CONCLUSIONS

While confirming the importance of studies' methodological quality, the results show that PGD is of public health relevance around the world, but especially common in less vulnerabled countries with better access to daily necessities and healthcare services, highlighting sociocultural impacts on grief processing. Further investigations of cross-national differences are needed.

Assessing conspiracist beliefs across societies: Validation of the Serbian adaptation of the Generic Conspiracist Beliefs Scale (GCBS)

Initial validation of the Generic Conspiracist Beliefs Scale (GCBS) identified five correlated factors: Government Malfeasance, Malevolent Global Conspiracies, Extraterrestrial Cover-up, Personal Well-being and Control of Information. Despite replications of this structure, ensuing research, mostly using translated versions of the GCBS (i.e., Persian and Japanese), has reported factorial alternatives. Concomitantly, researchers postulated that belief in conspiracies was higher in historically troubled societies (e.g., Serbia). To further assess the cultural stability of the five correlated factor solution and test the assumption that GCBS scores are affected by social-political instability, a Serbian adaptation of the GCBS was assessed alongside the standard English language version. Data were collected from Serbian (n = 259, 44.40% males) and UK samples (n = 402, 52.25% males). Within samples, confirmatory factor analysis replicated the five-factor solution. Additionally, national and gender invariance was confirmed. National comparisons (Serbia vs. UK) revealed that the Serbian sample scored higher on Government Malfeasance, Malevolent Global Conspiracies, Personal Well-being and Control of Information, whereas the UK sample scored higher on Extraterrestrial Cover-up. There were no gender differences on GCBS factors. Findings indicated that while the Serbian GCBS was interpreted similarly to the GCBS, societal factors influenced endorsement of belief facets.

Comparative Analysis of Outpatient Antibiotic Prescribing in Early Life: A Population-Based Study Across Birth Cohorts in Denmark and Germany

INTRODUCTION

Comparing antibiotic prescribing between countries can provide important insights into potential needs of improving antibiotic stewardship programs. We aimed to compare outpatient antibiotic prescribing in early life between children born in Denmark and Germany.

METHODS

Using the Danish nationwide healthcare registries and a German claims database (GePaRD, ~ 20% population coverage), we included children born between 2004 and 2016, and followed them regarding outpatient antibiotic prescriptions until end of enrollment or the end of 2018. We then determined the median time to first antibiotic prescription. Based on all prescriptions in the first 2 years of life, we calculated the rate of antibiotic treatment episodes and for the children's first prescriptions in this period, we determined established quality indicators. All analyses were stratified by birth year and country.

RESULTS

In the 2016 birth cohorts, the median time to first antibiotic prescription was ~ 21 months in Denmark and ~ 28 in Germany; the rate of antibiotic treatment episodes per 1000 person-years was 537 in Denmark and 433 in Germany; the percentage of prescribed antibiotics with higher concerns regarding side effects and/or resistance potential was 6.2% in Denmark and 44.2% in Germany. In the 2016 birth cohorts, the age at first antibiotic prescription was 50-59% higher compared to the 2004 birth cohorts; the rate of antibiotic treatment episodes was 43-44% lower.

CONCLUSIONS

Infants in Denmark received antibiotics markedly earlier and more frequently than in Germany, while quality indicators of antibiotic prescribing were more favorable in Denmark. Although both countries experienced positive changes towards more rational antibiotic prescribing in early life, our findings suggest potential for further improvement. This particularly applies to prescribing antibiotics with a lower potential for side effects and/or resistance in Germany.

Negotiation of collective and individual candidacy for long Covid healthcare in the early phases of the Covid-19 pandemic: Validated, diverted and rejected candidacy

This analysis of people's accounts of establishing their need and experiences of healthcare for long Covid (LC) symptoms draws on interview data from five countries (UK, US, Netherlands, Canada, Australia) during the first ∼18 months of the Covid-19 pandemic when LC was an emerging, sometimes contested, condition with scant scientific or lay knowledge to guide patients and professionals in their sense-making of often bewildering constellations of symptoms. We extend the construct of candidacy to explore positive and (more often) negative experiences that patients reported in their quest to understand their symptoms and seek appropriate care. Candidacy usually considers how individuals negotiate healthcare access. We argue a crucial step preceding individual claims to candidacy is recognition of their condition through generation of collective candidacy. "Vanguard patients" collectively identified, named and fought for recognition of long Covid in the context of limited scientific knowledge and no established treatment pathways. This process was technologically accelerated via social media use. Patients commonly experienced "rejected" candidacy (feeling disbelieved, discounted/uncounted and abandoned, and that their suffering was invisible to the medical gaze and society). Patients who felt their candidacy was "validated" had more positive experiences; they appreciated being believed and recognition of their changed lives/bodies and uncertain futures. More positive healthcare encounters were described as a process of "co-experting" through which patient and healthcare professional collaborated in a joint quest towards a pathway to recovery. The findings underpin the importance of believing and learning from patient experience, particularly vanguard patients with new and emerging illnesses.

Comparison of physical demanding paramedic work tasks between an Australian and Canadian ambulance service

Ambulance services require candidates to pass physical employment tests (PETs) to be deemed suitable for the paramedic role. Whilst some research has been undertaken to improve to relevance of these tests, they are often arbitrary and not based on research. The first phase in developing PETs is to generate a list of job tasks. To examine the utility of universal physical tasks tests for ambulance work, we conducted a cross-sectional study, utilising the results from previous work in a Canadian ambulance service to create a physical tasks checklist. These lists were then used by paramedics working for an Australian Service to identify physical tasks in their workplace, and the results from the two services were compared. Patient transfer tasks were similar in frequency and description for both services. Stretcher handling and manoeuvring was identified by Canadian paramedics as highly strenuous, (mean rating of perceived exertion (RPE) 7/10) but were rated mean RPE <3/10 by AV paramedics. Although some tasks between these two services were similar, the ambulance services in this study differed sufficiently with regard to equipment, training and policies mean that similarly titled jobs are not comparable, cross-nationally. Service specific job task analysis is required to develop PETs that ensure employees are specifically selected to meet the requirements of that service.

A cross-national comparison of the linkages between family structure histories and early adolescent substance use

Family structure can influence adolescent health with cascading implications into adulthood. Life course theory emphasizes how this phenomenon is dynamic across time, contextualized in policy systems, and grounded in processes of selection and socialization. This study used data from the U.S. (National Longitudinal Survey of Youth 1979 Child and Young Adults, n = 6,236) and U.K. (Millennium Cohort Study, n = 11,095) to examine associations between a single mother family structure between ages 0-14 and early adolescent substance use at age 14 across time and place, using inverse probability of treatment weighting to explore how results varied by selection into family structure. In both countries, single parenthood, regardless of its timing during childhood, consistently predicted adolescent substance use when samples were re-weighted to resemble the overall population. However, when samples were re-weighted so that their background characteristics resembled those of actual single parent families, there was little evidence that single parenting posed risks, suggesting that single parenting might matter less for adolescents who are likely to experience it (and vice versa). In addition, more generous welfare policy in the U.K. than in the U.S. did not appear to have ameliorated the observed role of single parenting in adolescent substance use. Findings supported a model of disadvantage saturation, where single parenting has little additional impact over the myriad other disadvantages that single parent families tend to experience, rather than a model of cumulative disadvantage, where single parenting compounds or adds to other disadvantages. Policy and interventions might more valuably focus on these other disadvantages than on family structure.

Cross-National Comparison of Religion as a Predictor of COVID-19 Vaccination Rates

We examined the effects of religiosity on COVID-19 vaccination rates using a cross-national comparison while controlling for socio-economic factors and culture. Our analysis, conducted on data from 90 countries representing 86% of the world population, showed that Christianity was negatively related to vaccination, while there was no relation with Islam, Buddhism, Hinduism, and nonbelief. The importance of religion, freedom of expression and belief, sex ratio, median age, and almost all cultural factors were not related to vaccination, whereas Human Development Index was. The influence of different religions on vaccination rates has also been described.

Development of a physical function outcome measure to harmonize comparisons between three Asian adult populations

PURPOSE

The purpose of this study was to use modern measurement techniques and create a precise functional status metric for Asian adults.

METHODS

The study subjects included Asian American adults from the 2012 Health and Retirement Study (n = 211), Chinese adults in the China Health and Retirement Longitudinal Study (n = 13,649), and Korean adults in the Korean Longitudinal Study of Aging (n = 7,486). The Rasch common-item equating method with nine self-care and mobility items from the three databases were used to create a physical function measure across the three Asian adult populations.

RESULTS

The created physical function measure included 23 self-care and mobility tasks and demonstrated acceptable psychometric properties (unidimensional, local independence, no misfit, no differential item functioning). A significant group difference in the estimated physical function across the three Asian adult populations ([Formula: see text] = 445.21, p < 0.0001) was identified. The American Asian adults (5.16 logits) had better physical function compared to the Chinese (4.15 logits) and Korean adults (3.32 logits).

CONCLUSION

Since the outcome measure was calibrated with the population-representative Asian samples, this derived physical function measure can be used for cross-national comparisons between the three countries. Using this precise functional status metric can help to identify factors that influence health outcomes in other Asian countries (China and Korea). This has the potential to generate numerous benefits, such as international disability monitoring and health-related policy development, improved shared decision making, and international syntheses of research findings.

Gender Differences in Perceived Family Involvement and Perceived Family Control during Emerging Adulthood: A Cross-Country Comparison in Southern Europe

The aim of the present study was to explore gender differences in perceived parental involvement and perceived psychological and behavioral control during emerging adulthood in two Southern European countries (Spain and Portugal). Data were collected from 491 Portuguese and 552 Spanish undergraduate emerging adults (53.7 % women and 46.3 % men) aged between 18 and 29 years (M = 20.24 and SD = 2.12). Results indicated that women perceived higher levels of parental involvement than men in both countries, and men perceived more behavioral control than women in Portugal. Furthermore, gender was found to moderate the association between perceived parental involvement and perceived psychological and behavioral control differently in each country. Taken together, our findings suggest that gender-differentiated socialization patterns persist during emerging adulthood and that these patterns may be affected by the sociocultural context.

Between "Medical" and "Social" Egg Freezing : A Comparative Analysis of Regulatory Frameworks in Austria, Germany, Israel, and the Netherlands

Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between "medical" and "social" egg freezing (MEF and SEF)-contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the "regulatory boundary-work" around the "medical"-"social" distinction in different egg freezing regulations. Based on systematic documents' analysis we present a cross-national comparison of the way the "medical"-"social" differentiation finds expression in regulatory frameworks in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: (1) the definition of MEF and its distinctiveness-highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it (less clear in Austria and Germany, detailed in Israel and the Netherlands); and (2) hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between "medical" and "social" are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects.

Explaining intention to reduce red and processed meat in the UK and Italy using the theory of planned behaviour, meat-eater identity, and the Transtheoretical model

This study aimed to contribute to the growing literature investigating the psychosocial factors associated with intentions to reduce red and processed meat consumption, given the significant negative impact of meat on public health and in contributing to climate change. A framework combining the Theory of Planned Behaviour with meat-eater identity and the Transtheoretical Model was used to explain intention to reduce red and processed meat consumption across participant samples in the UK and Italy, to identify the factors involved in encouraging behaviour change whilst also considering differences in culinary practices. University students in the UK (n = 320) and Italy (n = 304) completed an online survey including measures from the Theory of Planned Behaviour and the Transtheoretical Model, as well as a measure of meat-eater identity. The results showed differences in the relative impact of subjective norm, perceived behavioural control, and meat-eater identity, on behavioural intention across the different stages of change and across the two countries. On the other hand, attitude remained a stable predictor across the different stages of change and in both countries. The results are discussed in relation to existing literature, with the goal of increasing understanding of how reduced meat consumption might be encouraged across different populations.

The Effect of Childhood Socioeconomic Position and Social Mobility on Cognitive Function and Change Among Older Adults: A Comparison Between the United States and England

OBJECTIVES

This study aims to examine the relationship between childhood socioeconomic position (SEP) and cognitive function in later life within nationally representative samples of older adults in the United States and England, investigate whether these effects are mediated by later-life SEP, and determine whether social mobility from childhood to adulthood affects cognitive function and decline.

METHOD

Using data from the Health and Retirement Study (HRS) and the English Longitudinal Survey of Ageing (ELSA), we examined the relationships between measures of SEP, cognitive performance and decline using individual growth curve models.

RESULTS

High childhood SEP was associated with higher cognitive performance at baseline in both cohorts and did not affect the rate of decline. This benefit dissipated after adjusting for education and adult wealth in the United States. Respondents with low childhood SEP, above median education, and high adult SEP had better cognitive performance at baseline than respondents with a similar childhood background and less upward mobility in both countries.

DISCUSSION

These findings emphasize the impact of childhood SEP on cognitive trajectories among older adults. Upward mobility may partially compensate for disadvantage early in life but does not protect against cognitive decline.

Sibling Similarity in Education Across and Within Societies

The extent to which siblings resemble each other measures the omnibus impact of family background on life chances. We study sibling similarity in cognitive skills, school grades, and educational attainment in Finland, Germany, Norway, Sweden, the United Kingdom, and the United States. We also compare sibling similarity by parental education and occupation within these societies. The comparison of sibling correlations across and within societies allows us to characterize the omnibus impact of family background on education across social landscapes. Across countries, we find larger population-level differences in sibling similarity in educational attainment than in cognitive skills and school grades. In general, sibling similarity in education varies less across countries than sibling similarity in earnings. Compared with Scandinavian countries, the United States shows more sibling similarity in cognitive skills and educational attainment but less sibling similarity in school grades. We find that socioeconomic differences in sibling similarity vary across parental resources, countries, and measures of educational success. Sweden and the United States show greater sibling similarity in educational attainment in families with a highly educated father, and Finland and Norway show greater sibling similarity in educational attainment in families with a low-educated father. We discuss the implications of our results for theories about the impact of institutions and income inequality on educational inequality and the mechanisms that underlie such inequality.

Attitudes and beliefs about medical cannabis among social work students: Cross-national comparison

OBJECTIVES

Worldwide, considerable attention is being given to cannabis use for medical conditions. In the current study, we sought to assess attitudes and beliefs about MC among social work students from the US and Israel.

METHODS

We sought to assess attitudes and beliefs about MC among a sample of 417 social work students (230 from the US and 187 from Israel) who voluntarily participated in an anonymous online survey. Chi-square tests were used to analyze differences between groups.

RESULTS

Most of the US and Israeli participants (84.3 % and 96.7 %, respectively) reported no formal education about MC; and, they would recommend MC for their clients. Participants who reported any cannabis use, compared to non-users, were more likely to believe MC could benefit physical or mental health and less inclined to believe use of the substance poses serious physical or mental health risks. Secular, compared to religious students, believed it has more benefits for physical and/or mental health.

CONCLUSIONS

Our findings evidence a considerable dearth of formal evidence-based education about cannabis for medical conditions in two university-based cohorts, despite beliefs in MC as useful for physical and mental health conditions. Efforts to develop curricula and training programs for social work students are needed since they will be among key professionals addressing client needs from health care and counseling perspectives.

Do multigenerational living arrangements influence depressive symptoms in mid-late life? Cross-national findings from China and England

BACKGROUND

While living alone predicts depression in diverse ageing populations, the impact of multigenerational living is unclear. This study compared mid-late life depressive symptoms by living arrangements between societies with distinct kinship ties.

METHODS

Repeated data on depressive symptoms and living arrangements over 4 years from 16,229 Chinese (age≥45) and 10,403 English adults (age≥50) were analyzed using multilevel mixed-effects logistic regression. Elevated depressive symptoms were identified using the Center for Epidemiological Depression Scale criteria in each study.

RESULTS

Higher odds ratios (ORs) of elevated depressive symptoms were found in both Chinese and English adults aged<60 living with no partner but with children/grandchildren, compared to those living with a partner only. These ORs were greater for men (Chinese men: 3.09, 95% confidence interval: 2.00-4.78; English men: 3.44, 1.36-8.72) than for women (Chinese women: 1.77, 1.23-2.56; English women: 2.88, 1.41-3.67), after controlling for socioeconomic position, health behaviors, and health status. This male disadvantage was also observed for English, but not for Chinese, adults aged<60 living alone. For adults aged 60+, the increased odds among those living with no partner but with children/grandchildren and those living alone were smaller in both countries.

LIMITATIONS

Bias may exist because depressed participants are more likely to experience divorce or separation prior to baseline.

CONCLUSIONS

The relationship between living arrangements and depressive symptoms appears robust and consistent across social contexts, although the mechanisms differ. The protective role of partners in both China and England supports targeting those who do not live with partners to reduce depression.

Diverging ideas of health? Comparing the basis of health ratings across gender, age, and country

BACKGROUND

Self-rated health (SRH) is arguably the most widely used generic health measurement in survey research. However, SRH remains a black box for researchers. In our paper, we want to gain a better understanding of SRH by identifying its determinants, quantifying the contribution of different health domains to explain SRH, and by exploring the moderating role of gender, age groups, and the country of residence.

METHOD

Using data from 61,365 participants of the fifth wave (2013) of the Survey of Health, Ageing and Retirement in Europe (SHARE) living in fifteen European countries, we explain SRH via linear regression models. The independent variables are grouped into five health domains: functioning, diseases, pain, mental health, and behavior. Via dominance analysis, we focus on their individual contribution to explaining SRH and compare these contributions across gender, three age groups, and fifteen European countries.

RESULTS

Our model explains SRH rather well (R² = .51 for females/.48 for males) with functioning contributing most to the appraisal (.20/.18). Diseases were the second most relevant health dimension (.14/.16) followed by pain (.08/.07) and mental health (.07/.06). Health behavior (.02/.01) was less relevant for health ratings. This ranking held true for almost all countries with only little variance overall. A comparison of age groups indicated that the contribution of diseases and behavior to SRH decreased over the life-course while the contribution of functioning to R² increased.

CONCLUSION

Our paper demonstrates that SRH is largely based on diverse health information with functioning and diseases being most important. However, there is still room for idiosyncrasies or even bias.

Does Adolescent Alcohol Harm Minimization Policy Exposure Reduce Adult Alcohol Problems? A Cross-National Comparison

PURPOSE

Adolescent alcohol use carries risks for problem behaviors, such as injury and school dropout, as well as increases the risk of alcohol dependence later on, making public health approaches that curb youth alcohol use a key concern. The present study uses a two-state comparison of alcohol-related policies in Victoria, Australia and Washington State, U.S. (harm minimization in Australia and zero tolerance in the U.S.) to examine whether youth alcohol use in each state is related to alcohol-related problems in young adulthood.

METHODS

Data were drawn from the International Youth Development Study (N = 1,965) that followed youth in Victoria and Washington states from age 13 years, with follow-up at ages 14 and 15 years, and then again at age 25 years. Multiple-group structural equation modeling was used to test whether early alcohol use was equally related to alcohol problems (measured by the Alcohol Use Disorder Identification Test) at age 25 years and whether the relationship was moderated by family and school environments that were tolerant of youth drinking and by gender.

RESULTS

Youth in Victoria reported greater rates of alcohol use compared with youth in Washington, as well as more permissive family and school environments. Early alcohol use was equally associated with Alcohol Use Disorder Identification Test problems at age 25 years in the two nations, and none of the moderators significantly changed the association.

CONCLUSIONS

Results suggest that harm minimization policies adopted in Victoria are less effective at reducing alcohol problems during young adulthood compared with the stricter zero-tolerance approaches adopted in Washington State.

Separation and Elevated Residential Mobility: A Cross-Country Comparison

This study investigates the magnitude and persistence of elevated post-separation residential mobility (i.e. residential instability) in five countries (Australia, Belgium, Germany, the Netherlands, and the UK) with similar levels of economic development, but different welfare provisions and housing markets. While many studies examine residential changes related to separation in selected individual countries, only very few have compared patterns across countries. Using longitudinal data and applying Poisson regression models, we study the risk of a move of separated men and women compared with cohabiting and married individuals. We use time since separation to distinguish between moves due to separation and moves of separated individuals. Our analysis shows that separated men and women are significantly more likely to move than cohabiting and married individuals. The risk of a residential change is the highest shortly after separation, and it decreases with duration since separation. However, the magnitude of this decline varies by country. In Belgium, mobility rates remain elevated for a long period after separation, whereas in the Netherlands, post-separation residential instability appears brief, with mobility rates declining rapidly. The results suggest that housing markets are likely to shape the residential mobility of separated individuals. In countries, where mortgages are easy to access and affordable rental properties are widespread, separated individuals can rapidly adjust their housing to new family circumstances; in contrast, in countries with limited access to homeownership and small social rental markets, separated individuals experience a prolonged period of residential instability.

Mind the "Happiness" Gap: The Relationship Between Cohabitation, Marriage, and Subjective Well-being in the United Kingdom, Australia, Germany, and Norway

Many studies have found that married people have higher subjective well-being than those who are not married. Yet the increase in cohabitation raises questions as to whether only marriage has beneficial effects. In this study, we examine differences in subjective well-being between cohabiting and married men and women in midlife, comparing the United Kingdom, Australia, Germany, and Norway. We apply propensity score–weighted regression analyses to examine selection processes into marriage and differential treatment bias. We find no differences between cohabitation and marriage for men in the United Kingdom and Norway, and women in Germany. However, we do find significant differences for men in Australia and women in Norway. The differences disappear after we control for selection in Australia, but they unexpectedly persist for Norwegian women, disappearing only when we account for relationship satisfaction. For German men and British and Australian women, those with a lower propensity to marry would benefit from marriage. Controls eliminate differences for German men, although not for U.K. women, but relationship satisfaction reduces differences. Overall, our study indicates that especially after selection and relationship satisfaction are taken into account, differences between marriage and cohabitation disappear in all countries. Marriage does not lead to higher subjective well-being; instead, cohabitation is a symptom of economic and emotional strain.

Associations of socioeconomic and religious factors with health: a population-based, comparison study between China and Korea using the 2010 East Asian social survey

Background

Cross-national comparisons of the associations of socioeconomic and religious factors with health can facilitate our understanding of differences in health determinants between countries and the development of policies to reduce health differentials appropriate to each country. However, very few such studies have been conducted in East Asia.

Methods

This study set out to compare the associations of socioeconomic and religious factors with health in China and Korea using the 2010 East Asian Social Survey, which was based on nationally representative samples. The study participants included 4980 individuals, 3629 in China and 1351 in Korea, aged ≥20 years. The dependent variable, individuals’ self-rated health, was categorized into poor, good, and excellent. Socioeconomic (education, employment, household income, and self-assessed social class) and religious factors (affiliation) were used as independent variables of interest. A multinomial logistic regression was performed with and without adjustments for factors such as demographics, health-related risks, the health system, and social capital.

Results

According to the results, China had a higher proportion of individuals who reported excellent health than did Korea (57.4% vs. 52.0%). After adjusting for all studied confounders, we found that the employment, household income, and social class gradient in health were significant in China, whereas the education and religion gradients in health were significant in Korea. For example, the odds ratio for poor health versus excellent health among those in the highest social class was 0.47 (95% CI, 0.27–0.84), compared to that of people in the lowest social class in China; and this odds ratio in people with college education or higher was 0.28 (95% CI, 0.14–0.59) compared to that of people with elementary school education or lower in Korea.

Conclusions

These findings demonstrate the important role of socioeconomic and religious factors in health in China and Korea as well as clear differences in this regard. Further cross-national studies are needed to provide a better understanding of the relationship between socioeconomic and religious factors and health and to draft appropriate health improvement policies in both countries.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6380-y) contains supplementary material, which is available to authorized users.

Drug-related police encounters across the globe: How do they compare?

BACKGROUND

Drug law enforcement subsumes the majority of drug policy expenditure across the globe. Fuelled by knowledge that much of this investment is ineffective or counter-productive there have been increasing calls for cross-national comparisons to identify where policing approaches differ and what types of approaches may be more effective. Yet, to date cross-national comparison of drug law enforcement has proven a methodologically hazardous affair. Using a new drug policing module added to the 2017 Global Drug Survey, this study seeks to provide the first cross-national comparison of the incidence, nature and intensity of illicit drug-related police encounters amongst people who use drugs.

METHODS

The Global Drug Survey was administered in late 2016. Across 26 countries including Australia, Germany, Italy, Mexico, Switzerland, the UK and the USA a total of 45,942 people who had recently used drugs completed the drug policing module. Key variables assessed included the incidence and frequency of drug-related police encounters in the last 12 months that involved: a) being stopped and searched; b) encountering a drug detection dog; c) being given a caution or warning; d) being charged and arrested; and e) paying a bribe. Multi-level models were used to control for pre-existing national differences in drug use prevalence and non-drug specific policing (including the total number of police personnel in each country).

RESULTS

Drug-related police encounters were most commonly reported in Italy and Scotland. Conversely, police encounters were most likely to lead to arrest in Norway, Finland and Sweden. The type and locations of encounters further differed across countries, with for example stop and search most reported in Greece and Colombia, and encounters with drug detection dogs most reported in Scotland, Italy, UK and Australia. Multi-level models showed that the incidence of reported policing encounters continued to differ significantly across countries after controlling for pre-existing national differences in drug use prevalence and policing, and that drug policing encounters were 4 to 14 times more common in some nations than others.

CONCLUSION

The findings unearth significant cross-national differences in the incidence and nature of drug-related policing of people who use drugs. This suggests that there may be opportunities for countries to learn from each other about how and why they differ, and the potential benefits of switching to lower intensity modes of drug policing.

Visitor Preferences for Visual Changes in Bark Beetle-Impacted Forest Recreation Settings in the United States and Germany

Extensive outbreaks of tree-killing insects are increasing across forests in Europe and North America due to climate change and other factors. Yet, little recent research examines visitor response to visual changes in conifer forest recreation settings resulting from forest insect infestations, how visitors weigh trade-offs between physical and social forest environment factors, or how visitor preferences might differ by nationality. This study explored forest visitor preferences with a discrete choice experiment that photographically simulated conifer forest stands with varying levels of bark beetle outbreaks, forest and visitor management practices, and visitor use levels and compositions. On-site surveys were conducted with visitors to State Forest State Park in Colorado (n = 200), Lake Bemidji State Park in Minnesota (n = 228), and Harz National Park in Germany (n = 208). Results revealed that the condition of the immediate forest surrounding was the most important variable influencing visitors' landscape preferences. Visitors preferred healthy mature forest stands and disliked forests with substantial dead wood. The number of visitors was the most important social factor influencing visitor landscape preferences. Differences in the influence of physical and social factors on visual preferences existed between study sites. Findings suggest that both visual forest conditions and visitor use management are important concerns in addressing landscape preferences for beetle-impacted forest recreation areas.

Socioeconomic background and high school completion: Mediation by health and moderation by national context

This study uses longitudinal data from the Norwegian Health Study linked with registry data (n = 13262) and the U.S. National Longitudinal Survey of Youth 1997 (n = 3604) to examine (1) whether adolescent health mediates the well-established relationship between socioeconomic background and successful high school completion, and (2) whether this mediated pathway of influence varies by national context. Adolescents from lower educated and lower income families reported poorer health, which negatively impacted their likelihood of graduating from high school. The partial mediational effect of adolescent health was stronger in the U.S. than in Norway. These results suggest that policies aimed at preventing high school dropout need to address adolescent health, in addition to the unequal opportunities derived from socioeconomic disadvantage.

Intergenerational Relations in Older Stepfamilies: A Comparison of France, Germany, and Russia

OBJECTIVES

Our study examines cross-national variations in intergenerational relations of partnered parents aged 50 and older with adult non-coresident children by family structure (intact vs stepfamilies) and parent-child relationship type (biological tie vs steprelation). We focus on three European countries-France, Germany, and Russia-which have in common a relatively large proportion of stepfamilies, but differ with regard to contextual characteristics potentially impacting the stepfamily-intergenerational-relations nexus.

METHOD

The analysis is based on data from the Generations and Gender Survey (Wave 1). Our pooled analytical sample consists of 14,309 parent-child relationships derived from responses by 6,590 surveyed parents with adult children living outside the parental household. We consider two core dimensions of intergenerational solidarity as dependent variables, namely frequency of contact and emotional closeness.

RESULTS

Our results support the notion of commonly weaker intergenerational relations in stepfamilies. We also observe differences between biological parent-child ties and steprelations. Compared with their French and German counterparts, there is a weaker association between having a steprelation and parent-child contact frequency as well as a stronger negative correlation between having a steprelation and emotional closeness among Russian respondents.

DISCUSSION

The observed cross-national differences are proposed to result from different economic incentives to form a stepfamily, translating into a stronger "functional" basis of stepfamily intergenerational relations in the Russian context.

Conceptual and procedural distinctions between fractions and decimals: A cross-national comparison

Previous work has shown that adults in the United States process fractions and decimals in distinctly different ways, both in tasks requiring magnitude judgments and in tasks requiring mathematical reasoning. In particular, fractions and decimals are preferentially used to model discrete and continuous entities, respectively. The current study tested whether similar alignments between the format of rational numbers and quantitative ontology hold for Korean college students, who differ from American students in educational background, overall mathematical proficiency, language, and measurement conventions. A textbook analysis and the results of five experiments revealed that the alignments found in the United States were replicated in South Korea. The present study provides strong evidence for the existence of a natural alignment between entity type and the format of rational numbers. This alignment, and other processing differences between fractions and decimals, cannot be attributed to the specifics of education, language, and measurement units, which differ greatly between the United States and South Korea.

Sales of macrolides, lincosamides, streptogramins, and amoxicillin/clavulanate in the in- and outpatient setting in 10 European countries, 2007-2010

Monitoring the use of antibiotics is relevant due to the public health impact of microbial resistance, adverse effects, and costs. We present data on the consumption of macrolides, lincosamides, streptogramins and amoxicillin/clavulanate (AMC) between 2007 and 2010 in the in-and outpatient healthcare setting in 10 European countries provided by IMS Health. Antibiotics were classified according to the anatomical therapeutic chemical classification and consumption was expressed in defined daily doses/1000 inhabitants/day (DIDs). We analysed the number of prescriptions by diagnostic codes between 2008 and 2010, based on the International Classification of Diseases, 10th revision (ICD-10). These ICD-10 codes were grouped into four main categories: respiratory infections, genitourinary infections, other infections and other diagnoses. In 2010, the consumption of macrolides and lincosamides ranged from 0.45 DIDs (Sweden) to 5.46 DIDs (Italy), and from 0.04 DIDs (Denmark) to 1.00 DID (Germany), respectively. Streptogramins were available in France, Germany, Italy, Norway, Spain and United Kingdom with a consumption of <0.001 DID exclusively in the hospital setting. The consumption of AMC ranged from <0.001 DIDs (Norway) to 11.67 DIDs (Spain). During the study period, the consumption of macrolides decreased, the consumption of AMC increased in most of European countries, and lincosamides varied very slightly. Macrolides and AMC were mainly prescribed for respiratory infections in all countries but United Kingdom, where most of the prescriptions were assigned to diagnostic codes not clearly related with an infection. Lincosamides were prescribed for the respiratory infections and other infections groups. There was a wide inter-country variability in the percentage of the prescriptions assigned to each of the diagnostic categories. The inter-country differences in the consumption of these antibiotics and their prescription by diagnostic categories point to an inappropriate use of antibiotics.

Equality and quality in education. A comparative study of 19 countries

This contribution assesses the performance of national education systems along two important dimensions: The degree to which they help individuals develop capabilities necessary for their successful social integration (educational quality) and the degree to which they confer equal opportunities for social advancement (educational equality). It advances a new conceptualization to measure quality and equality in education and then uses it to study the relationship between institutional differentiation and these outcomes. It relies on data on final educational credentials and literacy among adults that circumvent some of the under-appreciated conceptual challenges entailed in the widespread analysis of international student assessment data. The analyses reveal a positive relationship between educational quality and equality and show that education systems with a lower degree of institutional differentiation not only provide more educational equality but are also marked by higher levels of educational quality. While the latter association is partly driven by other institutional and macro-structural factors, I demonstrate that the higher levels of educational equality in less differentiated education systems do not entail an often-assumed trade-off for lower quality.

From "retailers" to health care providers: Transforming the role of community pharmacists in chronic disease management

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.

The dynamic relationships between union dissolution and women's employment: a life-history analysis of 16 countries

The specialization theory from Gary Becker is often used to explain the effect of women's work on the risk of divorce. The main argument is that women with little work experience have higher economic costs to exit marriage. Using the Fertility and Family Surveys, we test for 16 countries to what extent women's employment increases the risk of separation. We also more directly examine the role of economic exit costs in separation by investigating the effect of separated women's work history during the union on women's post-separation employment. The results imply that Becker was right to some extent, especially in contexts with little female employment support. However, in settings where women's employment opportunities are more ample, sociological or psychological theories have probably more explanatory power to explain the causes and consequences of union dissolution.

Macro-level age norms for the timing of sexual initiation and adolescents' early sexual initiation in 17 European countries

PURPOSE

To examine the relationship between country-level age norms for sexual initiation timing and early sexual initiation (ESI) among adolescent boys and girls.

METHODS

Nationally representative data from 17 countries that participated in the 2006/2007 European Social Survey (ESS-3, n = 33,092) and the 2005/2006 Health Behaviour in School-Aged Children Study (HBSC, n = 27,702) were analyzed. Age norms were measured as the average country-level response to an item asking the age at which ESS respondents believed someone is too young to have sexual intercourse. HBSC respondents (aged 14-16 years) self-reported age at sexual initiation, which we defined as early (<15 years) or not early (≥15 years or no initiation). Control variables included age, family affluence, perceived socioeconomic status, family living arrangement, substance use, school attachment, and country-level legal age of consent. Multivariable three-level logistic models with random intercepts were run separately by sex.

RESULTS

In multivariable analyses, higher overall age norms were associated with reduced likelihood of ESI among girls (AOR .60, 95% CI .45-.79); associations with ESI were stronger for parent cohort (ages 31-65 years) norms (AOR .37, 95% CI .23-.58) than for peer cohort (ages 15-20 years) norms (AOR .60, 95% CI .49-.74). For boys, overall norms were also significantly negatively associated with ESI (AOR .68, 95% CI .46-.99), as were parent cohort norms (AOR .66, 95% CI .45-.96). Peer cohort norms were not significantly related to boys' ESI.

CONCLUSION

Macrolevel cultural norms may impact adolescents' sexual initiation timing. Research exploring the sexual health outcomes of early initiators in countries with contrasting age norms is warranted.

Challenges of health measurement in studies of health disparities

Health disparities are increasingly studied in and across a growing array of societies. While novel contexts and comparisons are a promising development, this commentary highlights four challenges to finding appropriate and adequate health measures when making comparisons across groups within a society or across distinctive societies. These challenges affect the accuracy with which we characterize the degree of inequality, limiting possibilities for effectively targeting resources to improve health and reduce disparities. First, comparisons may be challenged by different distributions of disease and second, by variation in the availability and quality of vital events and census data often used to measure health. Third, the comparability of self-reported information about specific health conditions may vary across social groups or societies because of diagnosis bias or diagnosis avoidance. Fourth, self-reported overall health measures or measures of specific symptoms may not be comparable across groups if they use different reference groups or interpret questions or concepts differently. We explain specific issues that make up each type of challenge and show how they may lead to underestimates or inflation of estimated health disparities. We also discuss approaches that have been used to address them in prior research, note where further innovation is needed to solve lingering problems, and make recommendations for improving future research. Many of our examples are drawn from South Africa or the United States, societies characterized by substantial socioeconomic inequality across ethnic groups and wide disparities in many health outcomes, but the issues explored throughout apply to a wide variety of contexts and inquiries.

Analyses of welfare-state reform policies towards long-term senior care in a cross-European perspective

The aim of this article is to introduce a systematic, structured conceptual framework for the comparative analysis of welfare-state reform policies towards long-term senior care and the care structures in a cross-European perspective. A welfare state's policies on the long-term care of senior citizens frame the different aspects of their care: the care options of the older people, the employment situation of the different types of caregivers and the care quality. The actual structure of senior care is mainly based on the specific care-provision mix in a welfare state and on the main types of care employment. It is should not, however, be treated as a direct outcome of care policies in analyses of welfare-state policies, since the care recipients and care givers all act within the broader framework of the complex and often contradictory cultural, institutional, social and economic context-the specific 'care arrangement' of a country.

Key elements composing self-rated health in older adults: a comparative study of 11 European countries

Self-rated health (SRH) is a multidimensional measure, predictive of morbidity and mortality. Comparative studies of determinants, however, are rare due to a lack of comparable cross-national data. This paper contributes towards filling in this gap, using data for persons aged 50 or higher in 11 European countries from the SHARE study (2004). The analysis aims at identifying key elements composing SRH using multinomial logistic regression models. In addition, the homogeneity of associations across populations is assessed. The findings indicate that education, depression, chronic conditions, mobility difficulties, somatic symptoms and levels of physical activity constitute important components of SRH; ADLs and obesity, on the other hand, are not significant and IADLs are important only in a few countries. All these associations point to the expected direction and are homogeneous across countries. However, demographic factors, age and gender, though significant in many countries have divergent associations. Effects of smoking also differentiate between southern and northern Europe.

Loneliness in urban neighbourhoods: an Anglo-Dutch comparison

Past studies in the UK and the Netherlands indicate that loneliness varies significantly according to characteristics of older people's residential environment. This raises questions regarding potential neighbourhood influences on individuals' social relationships in later life. This article examines neighbourhood influences on loneliness, using multiple classification analysis on comparable empirical data collected in the UK and the Netherlands. UK data arise from a survey of 501 people aged 60+ in deprived neighbourhoods of three English cities. Netherlands data derive from the NESTOR Living Arrangements and Social Network survey, with a sub-sample of 3,508 people aged 60+ drawn from a nationally representative sample of older people, living in 11 municipalities. Both surveys incorporated the 11-item De Jong Gierveld Loneliness Scale. In addition to neighbourhood characteristics and indicators of health and social embeddedness, a typology of eight groups of persons was developed that accounted for individuals' age, sex, and partner status. While 13% of participants in the UK were severely lonely, the proportion in the Netherlands was just four per cent. Mean loneliness scores in the UK varied significantly between the neighbourhoods under investigation. Additionally, the evaluated quality of the residential neighbourhood accounted for a relatively large degree of variance in loneliness in both countries.

Self-rated health among older adults: a cross-national comparison

Self-rated health (SRH) may have different implications in various social and cultural settings. However, few studies are available concerning SRH among older persons across countries. The aim of this study was to analyse whether there are cross-national differences in the association between status characteristics, several diseases common among older persons, activities of daily living (ADL), and SRH. The study base was the Comparison of Longitudinal European Studies on Aging (CLESA), which includes data from six population-based studies on aging conducted in Finland, Israel, Italy, The Netherlands, Spain and Sweden. The study population comprised 5,629 persons, with participants from all countries except Italy. Logistic regression analyses were used to assess the relationship between status characteristics, health conditions, ADL and SRH. To examine whether the association among status characteristics, health conditions, ADL and outcome differed across the CLESA countries, interaction terms defined as "variable*country" were considered separately for each variable. Regression analyses revealed that sex, education, lifetime occupation, heart disease and respiratory disease were differently distributed across countries. Among homogeneous factors, marital status (OR=1.21), hypertension (OR=1.41), stroke (OR=1.67), diabetes (OR=2.15), cancer (OR=1.47), musculoskeletal diseases (OR=2.44), and ADL (OR=2.72) turned out to be significantly associated with fair or poor SRH. The results indicate that there are differences in self-ratings of health across countries. These differences cannot be explained entirely by status characteristics, self-reported diseases or functional ability. However, an important finding was that in all countries most of the indicators of medical and functional health were homogeneously associated with SRH.

Contacts between elderly parents and their children in four European countries: current patterns and future prospects

Frequency of contacts with the family is an indicator of the strength of intergenerational exchange and potential support for older people. Although the availability of children clearly represents a constraint on potential family support, the extent of interaction with and support received from children depends on factors other than demographic availability alone. This study examined the effects of socio-economic and demographic variables on weekly contacts with children in Great Britain, Italy, Finland and The Netherlands using representative survey data which included information on availability of children and extent of contact. Our results confirm the higher level of parent adult-child contact in Italy than in northern European countries, but levels of contact in all the countries considered were high. Multivariate analysis showed that in most countries characteristics such as divorce were associated with a reduced probability of contact between fathers and children; in Finland this also influenced contact between mothers and children. Analyses are also included of possible future scenarios of contact with children that combine the observed effects of the explanatory variables with hypothetical changes in population distribution.

Disability-free life expectancy: a cross-national comparison of six longitudinal studies on aging. The CLESA project

Disability-free life expectancy (DFLE) was compared in six countries taking part in the Cross-national Determinants of Quality of Life and Health Services for the Elderly (CLESA) project. Data from six existing longitudinal studies were used: TamELSA (Tampere, Finland), CALAS (Israel), ILSA (Italy), LASA (The Netherlands), Aging in Leganés (Leganés, Spain) and SATSA (Sweden). A harmonised four-item disability measure (bathing, dressing, transferring, toileting) was used to calculate DFLE; the harmonised measure was dichotomised into 'independent in all four activities' vs. 'dependent in at least one'. Calculations of DFLE were made using the multistate life table approach and the IMaCh program (INED/EuroREVES, http://eurorevesinedfr/imach/) for subjects aged 65-89 years. Prevalence ratios of disability varied significantly across countries, with Italy and Leganés having the highest percentages among men and among women, respectively, while The Netherlands presented the lowest for both sexes. At 75 years of age the estimated total life expectancy among men ranged from 7.8 years in Tampere and Sweden to 9.0 years in Israel; among women it ranged from 9.5 years in Israel to 11.6 years in Italy. For both sexes Italy showed the lowest total life expectancy without disability (72% among men, 61% among women) and Sweden the highest (89% among men and 71% among women). The results yielded a north/south gradient, with residents in Tampere, The Netherlands and Sweden expected to spend a higher percentage of their lives without disability than those in Italy, Israel and Leganés.