Changing perceptions of general health in the Kayseri Province, Turkey in 2004 and 2017: A population-based study

Aim

Self-rated health (SRH) and health-related quality of life (HRQoL) have closely related outcomes in measuring general health status in community-based studies. The aim of this study is to determine changes in the self-perceived overall health of people and affected factors by comparing the findings of two studies conducted in the same research area.

Methods

Both studies were conducted using the same measurement tools in households determined by random sampling techniques in the same research areas. The first and second studies were conducted with 1,304 and 1,533 people residing in 501 and 801 households in 2004 and 2017, respectively. The demographic data form, the Nottingham Health Profile (NHP), and a single-item SRH questionnaire were used for data collection.

Results

The rate of good SRH increased from 56% to 70% while the average NHP score decreased from 30.87 to 20.34. The predictors of negative health perceptions were the presence of chronic diseases (OR 3.4-2.7-times higher), being female (OR.1.4-1.5 times higher), and the completion of primary education only (OR. 2.7-2.8 times higher) both 2004 and 2017. Living 500-1,000 m from the nearest healthcare facility was the main protective variable against poor SRH.

Conclusions

Good SRH and HRQoL have increased significantly over time. Chronic diseases, education, and gender are the strongest predictors of poor SRH.

Age, Period, and Cohort Effects on Activities of Daily Living, Physical Performance, and Cognitive Functioning Impairment Among the Oldest-Old in China

BACKGROUND

The aim of this study was to examine the trends in impairment regarding activities of daily living (ADL), physical performance, and cognitive function among the oldest-old (those aged 80 and older) in China between 1998 and 2014.

METHODS

We used data on 34,297 oldest-old individuals from the seven waves of the Chinese Longitudinal Healthy Longevity Study. We estimated age, period, and cohort effects on the prevalence of self-reported ADL impairment, tested physical performance and cognitive function impairment using the age-period-cohort model.

RESULTS

Regarding age, the prevalence of ADL, physical performance, and cognitive function impairment were highest in the centenarians, but they did not increase with age in this population. Among the literate subgroup, the prevalence of cognitive impairment increased more rapidly with age than that in the illiterate subgroup. Regarding period, the prevalence of self-reported and tested physical impairment slowly increased between 1998 and 2014, but cognitive impairment remained stable. Regarding cohort, ADL impairment continuously decreased. However, physical and cognitive impairment remained stable after a brief decline in the early birth cohorts.

CONCLUSIONS

The results suggest that the age effect is still the most obvious effect regarding several types of functional impairment. The likelihood of a younger person experiencing functional impairment may not change significantly, but ADL is likely to be amenable to improvement resulting from improved medical and social care. Therefore, increased care for the oldest-old may considerably improve their quality of life, particularly regarding their basic ADL.

Disability Prior to Death Among the Oldest-Old in China

Background

To estimate the prevalence of disability during the last 3 years prior to death among the oldest-old (≥80 years) in China.

Methods

We used data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), a nationally representative study of the oldest-old in China. The analytic sample included 23,934 decedents who died between 1998 and 2014 and had at least one interview within the last 3 years of life. Disability was defined as being incontinent or needing assistance in performing one or more of five other essential activities (bathing, transferring, dressing, eating, and toileting).

Results

About 57.8% (weighted) of the study decedents were female. The prevalence of disability increased modestly from 36 months to 24 months prior to death (20% to 23%), more rapidly from 24-months to 12-months before death (23% to 31%), and substantially from 12 months before death to the last month of life (31% to 48%). The disability rates were lowest for participants who died between 80 and 89 years, intermediate for those who died between 90 and 99 years, and highest for those who died at age 100 or older, although the patterns over the 3-year period were comparable for the three age groups. At each time point prior to death, a higher percentage of women was disabled than men.

Conclusions

In this large nationally representative sample of the oldest-old in China, the prevalence of disability during the 3 years prior to death is high and is greater in women than men and those who die at the oldest ages.

Differences in the health behaviors of elderly individuals and influencing factors: Evidence from the Chinese Longitudinal Healthy Longevity Survey

INTRODUCTION

Health behaviors play an important role in determining individual health status; thus, understanding differences in the health behaviors of elderly individuals and their influencing factors is a prerequisite for the formulation and implementation of health behavior promotion policies for elderly individuals. The objectives of this study were to explore differences in health behaviors among Chinese elderly people and their influencing factors.

METHODS

Based on data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) in 2014, this paper applied latent class analysis (LCA) to explore differences in the health behaviors of elderly individuals in China and employed a multinomial logit model to identify the influencing factors that cause these differences.

RESULTS

Results showed that there are five classes of health behaviors among elderly individuals in China: passive, relatively passive, general, relatively positive, and positive, the proportions of which were 31.07%, 15.86%, 24.06%, 17.24%, and 11.76%, respectively. Community medical and health services, pension, living arrangements, and family income were the primary factors explaining differences in the health behaviors of elderly individuals. In addition, there were significant demographic differences in the health behaviors of elderly individuals in China, including gender, age, education, marital status, census register, region, and others.

CONCLUSION

There are significant differences in the behaviors of elderly individuals in China, and the behaviors of the majority of elderly people are not healthy. China is expected to invest more medical and health resources to tackle health prevention and management and to provide targeted education, guidance, and intervention in elderly health behaviors, urging them to control and correct risky health behaviors with a focus on elderly individuals that are the oldest, are females, have low education levels, and live in the countryside and in towns.

Are China's oldest-old living longer with less disability? A longitudinal modeling analysis of birth cohorts born 10 years apart

BACKGROUND

China has transitioned from being one of the fastest-growing populations to among the most rapidly aging countries worldwide. In particular, the population of oldest-old individuals, those aged 80+, is projected to quadruple by 2050. The oldest-old represent a uniquely important group-they have high demand for personal assistance and the highest healthcare costs of any age group. Understanding trends in disability and longevity among the oldest-old-that is, whether successive generations are living longer and with less disability-is of great importance for policy and planning purposes.

METHODS

We utilized data from successive birth cohorts (n = 20,520) of the Chinese oldest-old born 10 years apart (the earlier cohort was interviewed in 1998 and the later cohort in 2008). Disability was defined as needing personal assistance in performing one or more of five essential activities (bathing, transferring, dressing, eating, and toileting) or being incontinent. Participants were followed for age-specific disability transitions and mortality (in 2000 and 2002 for the earlier cohort and 2011 and 2014 for the later cohort), which were then used to generate microsimulation-based multistate life tables to estimate partial life expectancy (LE) and disability-free LE (DFLE), stratified by sex and age groups (octogenarians, nonagenarians, and centenarians). We additionally explored sociodemographic heterogeneity in LE and DFLE by urban/rural residence and educational attainment.

RESULTS

More recently born Chinese octogenarians (born 1919-1928) had a longer partial LE between ages 80 and 89 than octogenarians born 1909-1918, and octogenarian women experienced an increase in partial DFLE of 0.32 years (P = 0.004) across the two birth cohorts. Although no increases in partial LE were observed among nonagenarians or centenarians, partial DFLE increased across birth cohorts, with a gain of 0.41 years (P < 0.001) among nonagenarians and 0.07 years (P = 0.050) among centenarians. Subgroup analyses revealed that gains in partial LE and DFLE primarily occurred among the urban resident population.

CONCLUSIONS

Successive generations of China's oldest-old are living with less disability as a whole, and LE is expanding among octogenarians. However, we found a widening urban-rural disparity in longevity and disability, highlighting the need to improve policies to alleviate health inequality throughout the population.

Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study

BACKGROUND

The oldest-old (those aged ≥80 years) are the most rapidly growing age group globally, and are most in need of health care and assistance. We aimed to assess changes in mortality, disability in activities of daily living, and physical and cognitive functioning among oldest-old individuals between 1998 and 2008.

METHODS

We used data from the Chinese Longitudinal Healthy Longevity Study. Three pairs of cohorts aged 80-89 years, 90-99 years, and 100-105 years (in total, 19 528 oldest-old participants) were examined; the two cohorts in each pair were born 10 years apart, with the same age at the time of the assessment in the 1998 and 2008 surveys. Four health outcomes were investigated: annual death rate, Activities of Daily Living (ADL), physical performance in three tests and cognitive function measured by Mini-Mental State Examination (MMSE). We used different tests and multivariate regression analyses to examine the cohort differences.

FINDINGS

Controlling for various confounding factors, we noted that annual mortality among oldest-old individuals was substantially reduced between 0·2% and 1·3% in 1998-2008 compared with individuals of the same age born 10 years previously, and that disability according to activities of daily living had significantly reduced annually between 0·8% and 2·8%. However, cognitive impairment in the later cohorts increased annually between 0·7% and 2·2% and objective physical performance capacity (standing up from a chair, picking up a book from the floor, and turning around 360°) decreased anually between 0·4% and 3·8%. We also noted that female mortality was substantially lower than male mortality among the oldest-old, but that women's functional capacities in activities of daily living, cognition, and physical performance were worse than their male counterparts.

INTERPRETATION

Advances in medications, lifestyle, and socioeconomics might compress activities of daily living disability, that is, benefits of success, but lifespan extension might expand disability of physical and cognitive functioning as more frail, elderly individuals survive with health problems, that is, costs of success.

FUNDING

National Natural Science Foundation of China, National Institute on Aging/National Institutes of Health, United Nations Funds for Population Activities.

Looking Under the Street Lamp

Unwarranted policy implications may emerge from the inappropriates use of measures and simplistic interpretations of trends in the employment data for people with disabilities. An example of this phenomenon is the recent misuse of traditional measures of “work disability” in media reports which argue that nondiscrimination policy has not produced increases in these employment rates. The paper cites media reports with mistaken uses of standard measures and notes that such errors flourish in a political climate receptive to reversing the emphasis on inclusion in disability policy. However, standard measures of “work disability” confound individual and situational factors. Users who do not adequately understand the nonmedical dimensions of disability unwittingly interpret trends in traditional measures as ifthe only operative factor were individuals' impairments. In this paper, I present the logic by which opposite conclusions about the effects of nondiscrimination disability policy can be inferred from existing data as a result of this confounding.

How Indicators of Socioeconomic Status Relate to Physical Functioning of Older Adults in Three Asian Societies

The relationship between socioeconomic status and physical functioning is tested among older adults in Taiwan, Thailand, and the Philippines. Socioeconomic indicators are limited to education and income, and these are linked to several measures of functioning that are constructed using four specific items—having difficulties crouching, climbing stairs, lifting things, and walking. Depending on the outcome measure, samples are treated separately or pooled. Education is found to be associated with functional health in Taiwan but is a weaker predictor in Thailand and the Philippines. Income has strong associations in Taiwan and Thailand and only a moderate association in the Philippines. Interaction effects based on pooled data confirm that differences in associations exist across settings. These results lead to questions about the universality of the relationship. Explanations for differential effects are discussed, including the impact of national levels of development on health outcomes.

Interrupted Trajectories and Labor Force Participation

This study explored the effect of unplanned changes in disability and marital status on labor force participation for a sample of just under 6,000 men and women born between 1931 and 1941. It was based on Wave 1 (1992) through Wave 4 (1998) of the Health and Retirement Study data. Binomial hierarchical linear models were used to evaluate the change in the probability of working. Unplanned changes in disability and marital status had effects on labor force participation over and above the effects of the statuses themselves. These findings highlight the need for employer and government policies that minimize the stress that exists with unplanned events. Such policies might encourage higher labor force participation among workers who experience unplanned events that prompt them to exit the labor force earlier than they otherwise would have, with potentially adverse consequences for their subsequent socioeconomic status.

Midlife Trends in Activities and Disability

Objectives: This is the first analysis that demonstrates empirically the likely tie between activities (time spent) and disability (health-related difficulty in activities). We compare trends in activities and disability for Americans ages 55 to 69 in recent years, and assess cross-sectional linkages of activities and disability. Methods: Data are from the Health and Retirement Study, a longitudinal survey of community-dwelling U.S. adults. Trends are estimated by mixed-effects regression models (MRMs) with time, age, and time–age interaction predictors. Links of activities and disability also use MRM. Results: For midlife adults, hobbies/leisure and sports/exercise increased, repairs/yard decreased, and several activities had convex patterns; by contrast, disability prevalence was stable. Personal care hours rise with disability, but most activities decline. Discussion: Activities are more dynamic than disability, and time use is associated with disability. Taken together, the results encourage broader activities in disability measures to capture better disability’s scope and dynamics.

Physical and cognitive functioning of people older than 90 years: a comparison of two Danish cohorts born 10 years apart

BACKGROUND

A rapidly increasing proportion of people in high-income countries are surviving into their tenth decade. Concern is widespread that the basis for this development is the survival of frail and disabled elderly people into very old age. To investigate this issue, we compared the cognitive and physical functioning of two cohorts of Danish nonagenarians, born 10 years apart.

METHODS

People in the first cohort were born in 1905 and assessed at age 93 years (n=2262); those in the second cohort were born in 1915 and assessed at age 95 years (n=1584). All cohort members were eligible irrespective of type of residence. Both cohorts were assessed by surveys that used the same design and assessment instrument, and had almost identical response rates (63%). Cognitive functioning was assessed by mini-mental state examination and a composite of five cognitive tests that are sensitive to age-related changes. Physical functioning was assessed by an activities of daily living score and by physical performance tests (grip strength, chair stand, and gait speed).

FINDINGS

The chance of surviving from birth to age 93 years was 28% higher in the 1915 cohort than in the 1905 cohort (6·50% vs 5·06%), and the chance of reaching 95 years was 32% higher in 1915 cohort (3·93% vs 2·98%). The 1915 cohort scored significantly better on the mini-mental state examination than did the 1905 cohort (22·8 [SD 5·6] vs 21·4 [6·0]; p<0·0001), with a substantially higher proportion of participants obtaining maximum scores (28-30 points; 277 [23%] vs 235 [13%]; p<0·0001). Similarly, the cognitive composite score was significantly better in the 1915 than in the 1905 cohort (0·49 [SD 3·6] vs 0·01 [SD 3·6]; p=0·0003). The cohorts did not differ consistently in the physical performance tests, but the 1915 cohort had significantly better activities of daily living scores than did the 1905 cohort (2·0 [SD 0·8] vs 1·8 [0·7]; p<0·0001).

INTERPRETATION

Despite being 2 years older at assessment, the 1915 cohort scored significantly better than the 1905 cohort on both the cognitive tests and the activities of daily living score, which suggests that more people are living to older ages with better overall functioning.

FUNDING

Danish National Research Foundation; US National Institutes of Health-National Institute on Aging; Danish Agency for Science, Technology and Innovation; VELUX Foundation.

Use of the integrated health interview series: trends in medical provider utilization (1972-2008)

The Integrated Health Interview Series (IHIS) is a public data repository that harmonizes four decades of the National Health Interview Survey (NHIS). The NHIS is the premier source of information on the health of the U.S. population. Since 1957 the survey has collected information on health behaviors, health conditions, and health care access. The long running time series of the NHIS is a powerful tool for health research. However, efforts to fully utilize its time span are obstructed by difficult documentation, unstable variable and coding definitions, and non-ignorable sample re-designs. To overcome these hurdles the IHIS, a freely available and web-accessible resource, provides harmonized NHIS data from 1969-2010. This paper describes the challenges of working with the NHIS and how the IHIS reduces such burdens. To demonstrate one potential use of the IHIS we examine utilization patterns in the U.S. from 1972-2008.

A Half Century of Health Data for the U.S. Population: The Integrated Health Interview Series

The U.S. National Health Interview Survey (NHIS) is the world's longest survey time series of health data and a rich source of information on health conditions, behaviors, and care from the 1960s to the present. NHIS public-use files are difficult to use for long-term analysis, due to complex file structure, changes in questionnaire content, and evolving variable names and coding schemes. Researchers at the Minnesota Population Center have created the Integrated Health Interview Series (IHIS) to overcome these problems. IHIS provides access to thousands of consistently coded and well-documented NHIS variables on the Internet and makes it easy to analyze health trends and differentials. IHIS multiplies the value of NHIS data by allowing researchers to make consistent comparisons over half a century and thus to study U.S. health status as a dynamic process. This article describes the main features of IHIS and suggests fruitful avenues for historical research using these invaluable health data.

Health Measurement in Population Surveys: Combining Information from Self-reported and Observer-Measured Health Indicators

Our primary aim is to develop and validate a population health metric for survey-based health assessment that combines information from both self-reported and observer-measured health indicators. A secondary objective is to use this index to examine gender and socioeconomic differentials in the health status of older people. We use data from the second wave of the English Longitudinal Study of Ageing (ELSA) conducted in 2004 (N = 8,870). Information from three observer-measured and three self-reported health indicators was combined, using a latent variable modeling approach. A model that decomposed the manifest health indicators to valid health, systematic error, and random error was found to fit the data best. The latent health dimension represented somatic health, and was tested against three external criteria: height, waist-hip ratio, and smoking status. We present the Latent Index of Somatic Health (LISH), as well as a procedure for deriving the LISH in surveys employing both self- and observer-measured health indicators. Observer-measured and self-reported indicators were found to be equally biased in indexing population somatic health, with the exception of self-reports of functional limitations, which was the most reliable somatic health indicator. As expected, results showed that women had worse health than men and that socioeconomic advantage is associated with better somatic health.

The increasing value of education to health

This paper assesses how the relationship between health and educational attainment has changed over the last three decades. We examine trends in disease prevalence and self-reported health using the US National Health Interview Survey for five chronic conditions-arthritis, diabetes, heart disease, hypertension, and lung diseases. The sample is limited to non-Hispanic Whites ages 40-64 to focus on the value of education and not changing representation of minority populations. We find that health benefits associated with additional schooling rose over time by more than ten percentage points as measured by self-reported health status. This can be attributed to both a growing disparity by education in the probability of having major chronic diseases during middle age, and better health outcomes for those with each disease. The value of education in achieving better health has increased over the last 25 years; both in protecting against onset of disease and promoting better health outcomes amongst those with a disease. Besides better access to health insurance, the more educated increasingly adapted better health behaviors, particularly not smoking and engaging in vigorous exercise, and reaped the benefits of improving medical technology. Rising health disparities by education are an important social concern which may require targeted interventions.

Trends in health of older adults in the United States: past, present, future

The decline in late-life disability prevalence in the United States was one of the most important developments in the well-being of older Americans in the 1980s and 1990s, but there is no guarantee that it will continue into the future. We review the past literature on trends in disability and other health indicators and then estimate the most recent trends in biomarkers and limitations for both the population aged 65 and older and those aged 40 to 64, the future elderly. We then investigate the extent to which trends in education, smoking, and obesity can account for recent trends in limitations and discuss how these three factors might influence future prospects for late-life health. We find that improvements in the health of the older population generally have continued into the first decade of the twenty-first century. The recent increase in the proportion of the younger population needing help with activities of daily living is concerning, as is the doubling of obesity in the last few decades. However the increase in obesity has recently paused, and favorable trends in education and smoking are encouraging.

Health, Economic Resources and the Work Decisions of Older Men

We specify a dynamic programming model that addresses the interplay among health, financial resources, and the labor market behavior of men late in their working lives. We model health as a latent variable, for which self reported disability status is an indicator, and allow self-reported disability to be endogenous to labor market behavior. We use panel data from the Health and Retirement Study. While we find large impacts of health on behavior, they are substantially smaller than in models that treat self-reports as exogenous. We also simulate the impacts of several potential reforms to the Social Security program.

Ageing populations: the challenges ahead

If the pace of increase in life expectancy in developed countries over the past two centuries continues through the 21st century, most babies born since 2000 in France, Germany, Italy, the UK, the USA, Canada, Japan, and other countries with long life expectancies will celebrate their 100th birthdays. Although trends differ between countries, populations of nearly all such countries are ageing as a result of low fertility, low immigration, and long lives. A key question is: are increases in life expectancy accompanied by a concurrent postponement of functional limitations and disability? The answer is still open, but research suggests that ageing processes are modifiable and that people are living longer without severe disability. This finding, together with technological and medical development and redistribution of work, will be important for our chances to meet the challenges of ageing populations.

Does It Matter How You Slice It? The Relationship Between Population Ageing and Use of Hospital and Posthospital Care in the United States

In the context of demographic transition, one would expect public health planners to allocate resources according to changing needs. This paper explores the effects that definitions of population ageing have on the images of, and subsequent responses to, demographic transition in the United States. Data are drawn from the 1988 U.S. Census and from a 20-percent national random sample of Medicare patients during the same period (n = 1.9 million). Main findings are that supply and use of acute services do differ according to definitions and the way in which population ageing has occurred; that, regardless of definition, older people in high-ageing states make far greater use of posthospital home health care than in low-ageing states; and that, although individual-level clinical factors appear central to rehabilitative decisions, all states seem to use very old age (85-plus) as a proxy to determine who goes where, with low-ageing states also affected by structural constraints at the hospital and market levels.

Chronic disease and severe disability among working-age populations

BACKGROUND

Recent work has shown that rates of severe disability, measured by the inability to perform basic activities of daily living, have been rising in working age populations. At the same time, the prevalence of important chronic diseases has been rising, while others falling, among working age populations. Chronically ill individuals are more likely than others to have activity of daily living limitations.

OBJECTIVE

We examine the extent to which chronic disease trends can explain these disability trends.

DATA

We use nationally representative survey data from the 1984-1996 National Interview Survey, which posed a consistent set of questions regarding limitations in activities of daily living over that period.

METHODS

We decompose trends in disability into 2 parts-1 part due to trends in the prevalence of chronic disease and the other due to trends in disability prevalence among those with chronic disease.

RESULTS

: Our primary findings are that for working age populations between 1984 and 1996: (1) disability prevalence fell dramatically among the nonchronically ill; (2) rising obesity prevalence explains about 40% of the rise in disability attributable to trends chronic illness; and (3) rising disability prevalence among the chronically ill explains about 60% of the rise in disability attributable to trends in chronic illness.

CONCLUSIONS

Disability prevention efforts in working age populations should focus on reductions in obesity prevalence and limiting disability among chronically ill populations. Given the rise in disability among these population subgroups, it is unclear whether further substantial declines in elderly disability can be expected.

Feeling better? Trends in general health status

OBJECTIVES

We addressed three questions: Have recent improvements in old-age disability been mirrored in changes in self-reported general health status? Are general health status trends similar for younger and older Americans? Have changes in general health status been uniform across demographic and socioeconomic groups?

METHODS

Using logistic regression, we analyzed data from the 1982-2003 National Health Interview Surveys (n = 1,445,872 aged 18-69; n = 178,384 aged 70 and older).

RESULTS

The proportion of people aged 70 and older reporting disability declined at 1.38% per year and the proportion 70 and older reporting poor/fair health declined at 1.85% per year. There was less of a decline in reports of poor/fair health at younger ages. Trends for the 18-69 population showed widening health disparities by income but narrowing of the race/ethnicity and education gaps. In the older population, there was no change for those aged 80-84 and 85 and older, the race/ethnicity gap persisted, and both education and income differentials widened over time.

DISCUSSION

Declines in proportions reporting poor/fair health among the older population in recent decades mirror declines in disability. Although the younger population has not experienced such progress, its prevalence of poor/fair health is low throughout the 21-year analysis period. Of concern are the growing socioeconomic disparities in health for both younger and older populations.

Short-term trends in functional limitation and disability among older Asians: a comparison of five Asian settings

The objective of this paper is to examine short-term trends in the prevalence of limitation in Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and Nagi physical functioning tasks among persons age 60 years or older in five Asian settings: Indonesia, the Philippines, Singapore, Taiwan and the Beijing Municipality. The data come from recent panel surveys of older adults that span a period of 3-4 years during the mid to late 1990s. Results suggest a general trend toward an increase in functional limitation in four of the five settings, with the most pronounced increases occurring for the Nagi functioning tasks. Compositional differences in the population accounted for little of the increase. The paper discusses the potential implications of these results and places them in the context of past and current trends in functional limitation observed in the United States.

State social capital and individual health status

Recent studies have found that two state-level measures of social capital, average levels of civic participation and trust, are associated with improvements in individual health status. In this study we employ these measures, together with the Putnam index of state social capital, to examine several key aspects of the relationship between state social capital and individual health. We find that for all three measures, the association with health status persists after carefully adjusting for household income and that for two measures, mistrust and the Putnam index, the size of this association warrants further attention. Using the Putnam index, we find particular support for the hypothesis that social capital has a more pronounced salutary effect for the poor. Our findings generate both support for the social capital and health hypothesis and a number of implications for future research.

Worsening trends in adult health-related quality of life and self-rated health-United States, 1993-2001

OBJECTIVES

Health-related quality of life and self-rated health complement mortality and morbidity as measures used in tracking changes and disparities in population health. The objectives of this study were to determine whether and how health-related quality of life and self-rated health changed overall in U.S. adults and in specific sociodemographic and geographic groups from 1993 through 2001.

METHODS

The authors analyzed data from annual cross-sectional Behavioral Risk Factor Surveillance System surveys of 1.2 million adults from randomly selected households with telephones in the 50 states and the District of Columbia.

RESULTS

Mean physically and mentally unhealthy days and activity limitation days remained constant early in the study period but increased later on. Mean unhealthy days increased about 14% during the study period. The percentage with fair or poor self-rated health increased from 13.4% in 1993 to 15.5% in 2001. Health-related quality of life and self-rated health worsened in most demographic groups, especially adults 45-54 years old, high school graduates without further education, and those with annual household incomes less than $50,000. However, adults 65 years old or older and people identified as non-Hispanic Asian/Pacific Islander reported stable or improving health-related quality of life and self-rated health. In 18 of the states and the District of Columbia, mean unhealthy days increased, while only North Dakota reported a decrease.

CONCLUSION

Population tracking of adult health-related quality of life and self-rated health identified worsening trends overall and for many groups, suggesting that the nation's overall health goals as identified in the Healthy People planning process are not being met.

Trends in the health of the elderly

Health among the older population as measured by most dimensions has improved during the last two decades. Mortality has continued to decline, and disability and functioning loss are less common now than in the past. However, the prevalence of most diseases has increased in the older population as people survive longer with disease, and the reduction in incidence does not counter the effect of increased survival. On the other hand, having a disease appears to be less disabling than in the past.

Looking Forward to a General Theory on Population Aging

The main theories on population aging based on recent data on human longevity, life expectancy, morbidity changes, disability trends, and mortality decrease are presented and discussed within their own geographic, cultural, socioeconomic, and medical contexts. The complex interactions between all these components do not facilitate trend forecasting of aging population (healthy aging versus disability pandemic). In the context of population aging, four elements were introduced with their implications: 1) an increase in the survival rates of sick persons, which would explain the expansion of morbidity, 2) a control of the progression of chronic diseases, which would explain a subtle equilibrium between the decrease in mortality and the increase in disability, 3) an improvement of the health status and health behaviors of new cohorts of elderly people, which would explain the compression of morbidity, and eventually 4) an emergence of very old and frail populations, which would explain a new expansion of morbidity. Obviously, all these elements coexist today, and future trend scenarios-expansion or compression of disability-depend on their respective weights leading to the need of elaborating "a general theory on population aging." This theory has to be based on a world harmonization of functional decline measurements and a periodic "International Aging Survey" to monitor global aging through a sample of carefully selected countries.

Measuring health inequality using qualitative data

Many questions in health policy require an understanding of the distribution of health status across a given population and how it changes as a result of policy interventions. Since objective data on individual health status are often unavailable or incomplete, especially for populations with very low mortality, increasing use has been made of self-reported health status (SRHS) data, which record people's own perceptions of their health status. SRHS has been shown to be a strong predictor of objective health outcomes and indications, including mortality. Nevertheless, the qualitative or categorical nature of SRHS data prevents the straightforward use of traditional tools of distributional analysis, such as the Lorenz curve, in evaluating inequality. This paper presents a methodology for evaluating inequality when the data are qualitative rather than quantitative in nature. A partial inequality ordering is defined to indicate when a distribution is more "spread out" than another; a second partial ordering (first order dominance) is used to indicate when the overall health level rises. Both are applicable to qualitative data, such as SRHS, in that results do not depend on the numerical scaling assigned to the categories. The approach is illustrated using SRHS data from the National Health Interview Survey (NHIS) State Data Files for 1994, focusing on the distribution of SRHS within states.

Socioeconomic status and health among older adults in rural and urban China

OBJECTIVE

The association between socioeconomic status (SES) and health, which has proven to be quite robust, is rarely tested in societies where levels of economic development and systems of stratification differ from those in Western developed countries. This article examines associations in rural and urban China.

METHOD

Techniques include logit equation estimates of separate and pooled samples. The latter employ interaction terms to test rural and urban effects. Socioeconomic indicators include those more customarily used in these types of studies (e.g., education) and several that are less traditional (e.g., pension eligibility).

RESULTS

Results indicate associations exist in China. Bank savings is the strongest predictor. Some unexpected results are also found, including a positive association between socioeconomic status and chronic conditions (e.g., cardiovascular disease) among older adults in urban China.

DISCUSSION

Use and access to a health care professional might explain part of this anomaly.

Physical disability in The Netherlands: prevalence, risk groups and time trends

Physical disability represents an important health indicator of western populations. In this paper the prevalence of physical disabilities in The Netherlands is presented for four domains of disability-visual, hearing, mobility and activities of daily living (ADL) disability-with a focus on risk groups and time trends.Cross-sectional national health survey data (NetHIS) of 9 y, 1990-1998, presenting data on 62 352 persons of 16 y or over were used. All data were self-reported. About one-eighth of the research population had a physical disability, ie had at least major difficulty with one or more functions such as walking, seeing, hearing and washing. This figure increased from 1.7% in the age group of 16-24 y to 44.1% in the age group of 75 y or older. Risk groups were women, those living alone, those who were divorced or widowed and those with a low educational level. In the period 1990-1998, the prevalence did not change with the exception of the prevalence of mobility disability which dropped slightly with 0.2 percentage points per year due to decreasing prevalences among men. One conclusion is that the prevalence of disability is high and stable, and expected to increase in the future due to the ageing of the population.

Changing chronic disease rates and long-term declines in functional limitation among older men

Functional limitation (difficulty walking, difficulty bending, paralysis, blindness in at least one eye, or deafness in at least one ear) in the United States fell at an average annual rate of 0.6% among men aged 50 to 74 from the early twentieth century to the early 1990s. Twenty-four percent of this decline is attributable to reductions in the debilitating effects of chronic conditions, 37% is attributable to reduced rates of chronic diseases, and the remainder is unexplained. The findings have implications for theories of the impact of declining mortality rates on the health of elderly people.

Declining disability among the elderly

This paper analyzes evidence on changes in disability among the elderly and considers its implications. Disability among the elderly has declined by 1 percent or more per year for the past several decades. Strong evidence relates these changes to improved medical technology and to behavioral changes. Changes in socioeconomic status, disease exposure, and use of supportive aids are likely important as well, although their magnitude is difficult to gauge. Should disability improvements continue, the projected increase in medical spending resulting from technological changes in health care would be moderated, but not eliminated. Disability change also may facilitate an increase in age of retirement.

Trends in healthy life expectancy in the United States, 1970-1990: gender, racial, and educational differences

This paper examines healthy life expectancy by gender and education for whites and African Americans in the United States at three dates: 1970, 1980 and 1990. There are large racial and educational differences in healthy life expectancy at each date and differences by education in healthy life expectancy are even larger than differences in total life expectancy. Large racial differences exist in healthy life expectancy at lower levels of education. Educational differences in healthy life expectancy have been increasing over time because of widening differentials in both mortality and morbidity. In the last decade, a compression of morbidity has begun among those of higher educational status; those of lower status are still experiencing expansion of morbidity.

Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999

Survey evidence through the early 1990s generally suggests a reduction in disability in the elderly population of the United States. Because the evidence is not fully consistent, several authors have speculated about whether disability declines will continue. This paper reports results from the 1999 National Long-Term Care Survey on disability trends from 1982 through 1999. It is found that disability continued to decline in the 1994 to 1999 period, and that the decline was greater in the 1990s than in the 1980s. The disability decline from 1982 to 1989 was 0.26% per year, from 1989 to 1994 it was 0.38% per year, and from 1994 to 1999 it was 0.56% per year. In addition, disability declined by a greater percentage for blacks than for nonblacks over the 1989 to 1999 period.

Secular trends in self-reported functioning, need for assistance and attitudes towards life: 10-year differences of three older cohorts

OBJECTIVES

To compare the self-reported functional status of cohorts, born 10 years apart, when they were at equivalent ages: 75, 80, or 85.

DESIGN

Cross-sectional mailed survey of three birth cohorts in 1989 and 1999.

PARTICIPANTS

Random samples of older home-dwelling residents from birth cohorts 1904, 1909, and 1914 in 1989 ( N = 685) and the birth cohorts 1914, 1919, and 1924 in 1999 ( N = 2,047) were asked the same questions.

MEASUREMENTS

Self-reported physical functioning, need for assistance in daily living, and attitudes toward life.

RESULTS

Among 85-year-olds born in 1914 there was a significantly larger proportion able to go outdoors compared with 85-year-olds born in 1904 (72.9% vs 60.6% in women (P <.01) and 84.6% vs 63.6 % in men (P <.01), respectively). Similar trends were observed between the oldest cohorts concerning the need for assistance. The amount of publicly funded domestic help had reduced in the two oldest cohorts in 1999 compared with 1989 (20.3% vs 29.8% in 85-year-old women born in 1914 vs 1904 (P <.05); and 10.2 % vs 25.0% in 85-year-old men born 1914 vs 1904 (P <.05), but at the same time 75-year-old women born in 1924 had increased the use of private domestic help compared with 75-year-old women born in 1914. Significantly larger proportions of both men and women had plans for the future in all the cohorts in 1999 than in 1989.

CONCLUSIONS

Consistent yet small differences between the corresponding cohorts suggest that physical functioning and more-optimistic attitude toward life have increased and need for assistance has decreased over 10 years in the older population up to the age of 85.

Compression or expansion of morbidity? Trends in healthy-life expectancy in the elderly Austrian population between 1978 and 1998

The aim of our study is to test the theories of compression or expansion of morbidity on the basis of data on the elderly population of Austria. Our data come from four microcensus surveys for the years 1978, 1983, 1991, and 1998. We use self-perceived health ratings to calculate healthy-life expectancy for the elderly population aged 60-89. Because our data are based on four cross-sectional surveys, we devote the first part of the paper to the consequences of possible sampling and non-sampling errors in our analysis of time trends. We come to the conclusion that, although the absolute number of years lived in good health may be overestimated, the time trend in healthy-life expectancy over the 20 years most probably is unbiased. The second part of the paper describes trends in healthy-life expectancy for the Austrian population. Our results suggest that both healthy-life expectancy and the ratio of healthy years to life expectancy increased between 1978 and 1998. Thus, in Austria ill health seems to be more and more compressed into the later years of life. Contrary to Fries's hypothesis, however, life expectancy does not seem to be approaching a maximum average life span in Austria, as mortality rates at older ages have been continuously decreasing over the last 20 years.

Disability trends among elderly persons and implications for the future

OBJECTIVES

This article used a new data source to examine the issue of disability trends among elderly persons and examined the potential implications of these trends on future health and long-term care needs.

METHODS

We used the 1992-1996 Medicare Current Beneficiary Survey to examine time trends in rates of activities of daily living and instrumental activities of daily living disability and physical limitation among Medicare beneficiaries aged 65 and over. We used multinomial logit and least squares regression techniques to produce trend estimates that held the age, sex, race, and educational distributions constant and projected these trends into the future. Finally, we estimated the potential impact of disability decline on per capita Medicare spending on elderly persons.

RESULTS

We found that disability among elderly persons is declining and that the trend toward a more educated elderly cohort explains some, but not all, of this decline. In the absence of downward disability trends, per capita Medicare expenditures would have grown even faster than they have.

DISCUSSION

Although the decline in disability prevalence in recent years appears real, whether it continues has enormous implications for the size of the disabled population in the future and for the ability of the society to care for its disabled elderly members.

Gender differences in positive and negative self-assessments of health status in a national epidemiological study of Israeli aged

The literature in subjective health appraisals frequently notes that elderly women, more so than men, generally experience a lower quality of life in all major indicators (physical health status, functional ability, perceived income adequacy, social contacts, psychological distress, and cognitive ability). The current epidemiological study, of 1,352 reporting Israeli subjects between the ages of 75-94, was undertaken in order to obtain reliable estimates of "poor" and "excellent/good" self assessments of health in a national sample of aged; to identify the most significant correlates of "poor" and "excellent/good" assessments; and to ascertain whether the models of "poor" and "good/excellent" subjective health are different for elderly men and women. While it was found that women indeed rate their health as being poorer than men, of greater theoretical interest was the finding that the pattern of variables predicting to "poor" and "good/excellent" health are different for men and women. The findings point to the fact that the simple health self-evaluation question is not a unitary construct, but rather a complex attitudinal measure which yields different structural and conceptual results when controlling for the subjective health outcome ("poor" or "good/excellent") and when analyzing gender-dichotomized models.

Understanding the twentieth-century decline in chronic conditions among older men

I argue that the shift from manual to white-collar jobs and reduced exposure to infectious disease were important determinants of declines in chronic disease rates among older men from the early 1900s to the 1970s and 1980s. The average decline in chronic respiratory problems, valvular heart disease, arteriosclerosis, and joint and back problems was about 66%. Occupational shifts accounted for 29% of the decline; the decreased prevalence of infectious disease accounted for 18%; the remainder are unexplained. The duration of chronic conditions has remained unchanged since the early 1900s, but when disability is measured by difficulty in walking, men with chronic conditions are less disabled now than they were in the past.

Health inequality and population variation in fertility-timing

We estimate the impact of fertility-timing on the chances that children in poor urban African American communities will have surviving and able-bodied parents until maturity. To do so, we use census and vital statistics data to compute age- and sex-specific rates of mortality and functional limitation among prime-aged adult residents of impoverished African American areas in Harlem, Detroit, Chicago, and the Watts area of Los Angeles and for blacks and whites nationwide. Findings are consistent with the hypothesis that the early fertility-timing characteristic of poor urban African American populations mitigates some of the costs to families associated with excess mortality and early health deterioration in young through middle adulthood.

Evidence for decline in disability and improved health among persons aged 55 to 70 years: the Framingham Heart Study

OBJECTIVES

This study detected secular change in disability and health among persons aged 55 to 70 years, the life period when increases in disability and morbidity begin and retirement occurs.

METHODS

Cross-sectional comparisons were completed with data from similarly aged members of the original (n = 1760) and offspring (n = 1688) cohorts of the Framingham Heart Study, which represent 2 generations. Analyses were conducted by gender and on chronic disease subgroups by logistic regression.

RESULTS

There was substantially less disability in the offspring cohort than in the original cohort. Thirty-six percent of offspring men were disabled vs 52% of original cohort men (P = .001); among women, these proportions were 54% vs 72% (P = .001). Fewer offspring perceived their health as fair or poor and fewer had chronic diseases. Offspring were more physically active and less likely to smoke or consume high amounts of alcohol, but their average weight was greater. The secular decline in disability was strongly evident among individuals with chronic diseases.

CONCLUSIONS

Our findings depict a secular change toward a less disabled and globally healthier population in the period of life when retirement occurs.

Influenza and pneumococcal vaccine receipt in older persons with chronic disease: a population-based study

OBJECTIVE

To identify factors associated with receipt of the pneumococcal and influenza vaccines among community-dwelling older persons with chronic disease.

METHODS

A population-based sample of urban and rural Iowa adults age 65 years and older with one or more self-reported target medical conditions were interviewed by telephone. Information was obtained on aspects of health care access, which were examined as potential determinants of receipt of recommended vaccines.

RESULTS

A total of 787 interviews were completed (response rate = 68%; completion rate for screened, eligible subjects = 91%). Two-thirds (n = 531, 68%) reported influenza vaccination in the last year, and one-half (51%, n = 393) reported ever receiving the pneumococcal vaccine. Both vaccines were received at recommended intervals by 347 subjects (44%). Multivariable logistic regression identified the following factors independently associated with receipt of both vaccines: age 70 or greater (OR = 1.64, CI95 = 1.15, 2.32); married (OR = 1.41, CI95 = 1.03, 1.92); self-owned residence (OR = 0.57, CI95 = 0.33, 0.97); working (OR = 2.94, CI95 = 1.38, 6.18); increased number of target medical conditions (OR = 1.3 for each, CI95 = 1.09, 1.54); current prescription medication (OR = 2.04, CI95 = 1.32, 3.14); and a physician visit in the last year (OR = 2.53, CI95 = 1.52-4.19). Receipt of the vaccines was unrelated to geographic location in a rural area.

CONCLUSIONS

Despite their proven safety and efficacy, many persons with at least two indications to receive either vaccine remain unvaccinated. Among the elderly with chronic disease, predisposing and need factors were independently associated with receipt of both vaccines. Enabling factors assessed appeared less important in this population. Targeting of the elderly and those with chronic disease to receive recommended vaccines is needed to adequately protect these populations at risk.

Aging, health risks, and cumulative disability

BACKGROUND

Persons with lower health risks tend to live longer than those with higher health risks, but there has been concern that greater longevity may bring with it greater disability. We performed a longitudinal study to determine whether persons with lower potentially modifiable health risks have more or less cumulative disability.

METHODS

We studied 1741 university alumni who were surveyed first in 1962 (average age, 43 years) and then annually starting in 1986. Strata of high, moderate, and low risk were defined on the basis of smoking, body-mass index, and exercise patterns. Cumulative disability was determined with a health-assessment questionnaire and scored on a scale of 0 to 3. Cumulative disability from 1986 to 1994 (average age in 1994, 75 years) or death was the measure of lifetime disability.

RESULTS

Persons with high health risks in 1962 or 1986 had twice the cumulative disability of those with low health risks (disability index, 1.02 vs. 0.49; P<0.001). The results were consistent among survivors, subjects who died, men, and women and for both the last year and the last two years of observation. The onset of disability was postponed by more than five years in the low-risk group as compared with the high-risk group. The disability index for the low-risk subjects who died was half that for the high-risk subjects in the last one or two years of observation.

CONCLUSIONS

Smoking, body-mass index, and exercise patterns in midlife and late adulthood are predictors of subsequent disability. Not only do persons with better health habits survive longer, but in such persons, disability is postponed and compressed into fewer years at the end of life.