What is new?
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Comparisons of disability-free life expectancy between European countries has been hampered by a lack of harmonised disability measure. In our study, we show that the Global Activity Limitation Index (GALI) shows good agreement with other subjective and objective measures of function across 11 European countries.
What this adds to what is known- •
This is one of the first studies giving a quantitative evaluation of the GALI in more than one country.
What is the implication, what should change now- •
As the GALI is the measure underlying the EU structural indicator Healthy Life Years, it should be validated in all European countries particularly the Eastern European countries.
Health expectancies, combining information on mortality and morbidity, have become essential indicators of the health of our aging populations, where the quality of remaining life is seen at least as important as the quantity. Europe is no exception and indeed has now introduced a disability-free life expectancy (DFLE), called the Healthy Life Year (HLY) as the first European structural indicator on health [1]. These indicators are to be monitored annually by the Spring Council meeting (European Commission 2003 and 2004).
A major purpose of monitoring health expectancies is to determine whether the year-on-year increases in life expectancy, still evident in most of the countries, are accompanied by decreases in unhealthy life years (known as the compression of morbidity hypothesis) [2], [3], [4], [5] or by increases in unhealthy life years (expansion of morbidity) [2], [4], [5], [6]. Despite the commonly held view that the endpoint of the epidemiological transition is the compression of morbidity, Robine and Michel [5] have suggested that further life expectancy increases, and the emergence of greater numbers of the oldest old might result in further expansion of disability. Analyzing three chronological series, they have demonstrated that the proportion of years lived in good health have decreased in Australia, remained constant in Great Britain, and increased in Austria, and that this was related to the initial level of life expectancy. They suggest that expansion of disability goes with the highest life expectancy and compression with the lowest [5].
Although health expectancies are available for more than 50 countries worldwide, including many European countries, Robine and Michel's [5] hypothesis is difficult to confirm, because differences in the underlying health measure and in the methods of calculation hamper harmonization. To date cross-national comparisons of health expectancies across Europe have been few and have relied on post- rather than precollection harmonization. The Cross National Determinants of Quality of Life and Health Services for the Elderly Project (CLESA) is the first attempt to make a cross-national comparison of DFLE using data from five European countries (Finland, Italy, The Netherlands, Spain, and Sweden) and Israel [7]. Even when longitudinal analysis was possible, CLESA has major disadvantages, because the activities of daily living (ADL) measures were collected in different periods from 1987 to 1993 (baseline) and from 1990 to 2000 (follow-up), with various response categories, and with data being harmonized postcollection [8]. Although Italy showed the lowest total life expectancy without disability among both men (72%) and women (61%) and Sweden the highest (89% among men and 71% among women), it is difficult to determine whether or not these differences in DFLE are real. A few countries (France, United Kingdom, Belgium, Ireland, The Netherlands, United States, Switzerland, and Australia) have attempted to estimate dementia-free life expectancy, but again, cross-national comparisons are difficult because of differing diagnostic instruments, a lack of harmonization of case definitions, and, in some countries, omission of those in institutions [9], [10].
According to the recent RAND Corporation Europe report, HLY will be distinguished from other indicators of health expectancy by harmonization at the point of collection, which allows comparability across countries [11]. HLY is based on a Global Activity Limitation Index (GALI) question from the Statistics on Income and Living Conditions (SILC) survey. The GALI, which has been designed particularly for health expectancy comparisons across Europe [12], [13], has only been validated to date against other measures of health and function in one country, Belgium [12], [14]. Other than the GALI, there are only a very limited number of questions on health and functioning in the SILC, which restricts further validation of the GALI in other languages and cultures. However, the GALI was included in the Survey of Health and Retirement in Europe (SHARE) alongside a wide range of other disability measures. SHARE was based on the US Health and Retirement Survey and was conducted in 2004 on individuals aged 50 years and older in 11 European countries: Germany, Austria, Belgium, Denmark, Spain, France, Greece, Italy, The Netherlands, Sweden, and Switzerland.
As the GALI will be used to monitor levels of health within and between countries through the HLY indicator, it is important to understand what the GALI is actually measuring and to check its robustness. Using data from SHARE, this article aims to validate the GALI for the first time in multiple European countries and to investigate whether the GALI reflects similar levels of disability and functioning in different countries.