Original Article
The Global Activity Limitation Index measured function and disability similarly across European countries

https://doi.org/10.1016/j.jclinepi.2009.11.002Get rights and content

Abstract

Objective

This work aims to validate and increase understanding of the Global Activity Limitation Index (GALI), an activity limitation measure from which the new structural indicator Healthy Life Years is generated.

Study Design and Setting

Data from the Survey of Health and Retirement in Europe, covering 11 European countries and 27,340 individuals older than 50 years, was used to investigate how the GALI was associated with other existing measures of function and disability and whether the GALI was consistent or reflected different levels of health in different countries.

Results

The GALI was significantly associated with the two subjective measures of activities of daily living score and instrumental activities of daily living (IADL) score, and the two objective measures of maximum grip strength and walking speed (P < 0.001 in all cases). The GALI did not differ significantly between countries in terms of how it reflected three of the health measures, with the exception being IADL.

Conclusion

The GALI appears to satisfactorily reflect levels of function and disability as assessed by long-standing objective and subjective measures, both across Europe and in a similar way between countries.

Introduction

What is new?

  • 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
  1. 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
  1. 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.

Section snippets

Methods

The sample size for SHARE ranged from 947 (Switzerland) to 3,671 (Belgium) persons per participating country (Table 1), representing the noninstitutionalized population aged 50 years and older [15]. The SHARE main questionnaire consists of 20 modules (supplemented by a self-completion questionnaire). The GALI is self-reported, whereby an individual is asked “For the past six months at least, to what extent have you been limited because of a health problem in activities people usually do?” There

Results

The characteristics of the SHARE study sample are described with regard to country in Table 1. The country cohorts were fairly similar in terms of age and gender composition, with a mean age of between 63.9 years (The Netherlands) and 66.9 years (Spain) and percentage of males varying from 42.1% (Spain) to 47.4% (Sweden). The percentage describing themselves as limited varied considerably by country and was highest in Germany (49.5%) and lowest in Greece (30.4%). Other measures of disability

Discussion

The GALI is a new single-item disability measure developed to allow consistent monitoring of the health of the European population [1]. The GALI and two other single-item questionnaires on self-rated health and chronic morbidity form the Minimum European Health Module, which is included in the European Union Statistics of Income and Living Conditions Survey, now running in all 27 countries in the European Union. The importance of the GALI makes it imperative that its properties are fully

Acknowledgments

The SHARE data collection has been primarily funded by the European Commission through the 5th framework programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life). Additional funding came from the US National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG-4553-01, and OGHA 04-064). Data collection in Austria (through the Austrian Science Fund, FWF), Belgium (through the Belgian Science Policy Office), and Switzerland (through

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    Conflict of interest: There are no conflicts of interests.

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