9th Washington group, Dar Es Salaam October 2009
Population estimates of disability
The impact of including or not
the population living in institutions
Emmanuelle Cambois (INED, France)
For the EHLEIS program
% Disability, activity limitations, functional problems…
Householdpopulation
OutsideHouseholds
?
Context: Are disability statistics data representative of the whole population?
The health of the population is measured by health surveys that are most of the time onlybased on household population: difficulty to organise a survey in institution, various situation worldwide.
Shall we develop surveys in institutions to be able to compare?
How do we deal with this so far?
1> Proposing an aggregate health indicator, the disability free life expectancy, Sullivan was suggesting considering that living in institution was an expression of disability and recommended considering the prevalence of disability as 100% in institutions (Sullivan, 1971).
2> Eurostat calculation of Healthy Life years is only based on HH prevalence, tacitly assuming that the same prevalence can be observed in and outside HH
?
Collective HH
Medical, nursing, disability
% Disability, activity limitations, functional problems…
Householdpopulation
OutsideHouseholds
How relevant are these assumptions 2. A part of the population outside HH lives in collective HH and a part lives in nursing or health care institution.Differences btw countries?
?
?
% Disability, activity limitations, functional problems…
Collective HH
Medical, nursing, disability
Householdpopulation
OutsideHouseholds
Context3. To what extent the prevalence differs from the HHpopulation prevalence?
Assumptions> Proposing an aggregate health indicator, the disability free life expectancy, Sullivan was suggesting
considering that living in institution was an expression of disability and recommended considering the prevalence of disability as 100% in institutions (Sullivan, 1971).
While this can be reasonable assumption for nursing homes and long term hospital services, this can be consider as a quite strong assumption for other types of collective, while distinction can not be all the time be made with regular statistics
> Eurostat calculation of Healthy Life years is only based on HH prevalence, tacitly assuming that the same prevalence can be observed in and outside HH.
This assumption might be optimistic considering that part of the population is actually in poorest health than in HH, but it depends on the % of such institutions within the population living outside HH.
QuestionsWhat is the impact of these assumptions on estimates?
Is it worth for international comparison to address the issue of survey in institutions?
1.Looking at the European populations living outside HHWhat is the distribution between HH and population outside HH across Europe?What is the distribution of the care institutions in the population outside HH (3 countries)?
2.The impact on the level of prevalence of disability and on healthy life years?– - considering Sullivan vs. Eurostat on outside HH population– - considering Sullivan + + when li;ited to the care related institutions
3.What is the real prevalence of disability in institutions; in between the two assumptions
0%
1%
2%
3%
4%
5%
6%
7%
8%
Greece Hungary France Finland Ireland Denmark Estonia Austria Germany Lithuania CzechRepublic
Italy Cyprus
% Living outside HH
[65+] [65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[65+]
[15-29][15-29]
[15-29]
[15-29]
[15-29]
[15-29][15-29]
[15-29][15-29]
[15-29][15-29] [15-29]
[15-29]0%
1%
2%
3%
4%
5%
6%
7%
8%
Greece Hungary France Finland Ireland Denmark Estonia Austria Germany Lithuania CzechRepublic
Italy Cyprus
[65+] % for the 65+
[15-29] % for the [15-29]
% Living outside HH
0%
5%
10%
15%
20%
25%
30%
35%
[0-14] [15-19] [20-24] [25-29] [30-34] [35-39] [40-44] [45-49] [50-54] [55-59] [60-64] [65-69] [70-74] [75-79] [80-84] 85+
Netherlands
Ireland
France
Finland
Germany
Cyprus
Denmark
Czech Republic
Hungary
Estonia
Italy
Greece
Lithuania
Population living outside HH. Data from Eurostat circa 2000
1. The European populations living outside HH
What is the distribution between HH population and population outside HH across Europe? (example with 13 countries)
•From 3.5% in Greece to less than 1% in Italy or Cyprus•Large variation in the type of population regarding % in age groups
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
>25 25-34 35-44 45-54 55-64 65-74 75-84 85+
Care and nursing home
Care institutions
Institutions for disabled
Religious institutions
Other institution (assistance)
Jails
Residences for immigrants
Other
For students
Residences for children
Italy Men
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
>25 25-34 35-44 45-54 55-64 65-74 75-84 85+
Care and nursing home
Care institutions
Institutions for disabled
Religious institutions
Other institution (assistance)
Jails
Residences for immigrants
Other
For students
Residences for children
Italy Women
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-14 15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Old ages/Nursing homes
Long term care
Religious communities
For w orkers
Other
Other collective housing
Shelters
Itinerant
For students
France Men
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Old ages/Nursing homes
Long term care
Religious communities
For w orkers
Other
Other collective housing
Shelters
Itinerant
For students
France Women
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-14 15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Home for elderly
Nursing home
Psychiatric Hopsital
Institution for mentallyimpaired
Other institutions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-14 15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Home for elderly
Nursing home
Psychiatric Hopsital
Institution for mentallyimpairedOther institutions
1. The European populations living outside HH
What is the distribution of the institutions/collective HH in the population outside HH across Europe? Example with France, Italy, The Netherlands
0%
5%
10%
15%
20%
25%
30%
35%
[0-14] [15-19] [20-24] [25-29] [30-34] [35-39] [40-44] [45-49] [50-54] [55-59] [60-64] [65-69] [70-74] [75-79] [80-84] 85+
FranceFrance 2ItalyItaly 2NetherlandsNetherlands 2
Gap on the Eurostat estimates vs Sullivan with the care related institutions?
% living outside HH and % in nursing/care institutions
1. The European populations living outside HH
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
16+
65+
80+
16+
65+
80+
16+
65+
80+
16+
65+
80+
16+
65+
80+
France - Italy - latvia - TheNetherlands
- hungary
Household
Sullivan
Sullivan++
Men
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
16+
65+
80+
16+
65+
80+
16+
65+
80+
16+
65+
80+
16+
65+
80+
France - Italy - latvia - TheNetherlands
- hungary
Household
Sullivan
Sullivan++
Women
2. Impact of the assumptions on the prevalence of « Activity limitation »
+492 548
+125 342
+11 585
+59 293 +114 217
+199 021
+52 699
+13 5311 000 000
2 000 000
3 000 000
4 000 000
5 000 000
6 000 000
France Italie Latvia The Netherlands Hungary
Household
Sullivan
Sullivan+++ 4,3% + 1,4%
+ 1,2%
2. Effect on the prevalance of « Activity limitation »
The number of people with activity limitation in adult population
0
2
4
6
8
10
12
14
16
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
Yea
rs o
f h
ealt
hy
life
HLY Eurostat
DFLE Sullivan
Men
0
2
4
6
8
10
12
14
16
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
Yea
rs o
f h
ealt
hy
life
HLY
DFLE Sullivan
Women
2. Effect on HLY calculations
At age 65
0
12
24
36
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
HL
Y-D
FL
E (
in m
on
ths)
At birth
0
2
4
6
8
10
12
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
HL
Y-D
FL
E (
in m
on
ths) At 65
0
12
24
36
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
HL
Y-D
FL
E (
in m
on
ths)
0
2
4
6
8
10
12
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
HL
Y-D
FL
E (
in m
on
ths)
2. Effect on HLY calculations
At birth, gap from30 mth (Gr men) to 2.9 mth (Lth/Cy women)
At 65, gap from8 mth (Ir women) to <1 mth (Lth/Cy women
Differences in healthy life years according to Eurostat/Sullivan method (in months)
0
6
12
18
At birth At age 50 At age 65 At age 80
Mo
nth
s o
f lif
e ex
pec
tan
cy
Men
Women
2. Effect on HLY calculations
Number of years differences between HLY and DFLE in The Netherlands
• High institutionalization rate, due to high rate for elderly• Up to 1 year difference according to the assumption• Reduced to less than 10 month if limiting to « care related institutions »
2. Effect on HYL calculations
• Eurostat calculations overestimate the HLY to a different extent from one country to another regarding Sullivan assumption
• The gap reduces if considering only care related institutions
• How reliable could be Sullivan assumption compared to Eurostat? What could be the gap in prevalence of GALI in institution vs. HH or vs. 100%?
0%
10%
20%
30%
40%
50%
60%
70%
80%
20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
ADL in institutions
ADL in HH
Women, late 1990's
0%
10%
20%
30%
40%
50%
60%
70%
80%
20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
ADL in institutions
ADL in HH
Men, late 1990's
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Functional limitations in institutions
Functional limitations in HH
Men, late 1990's
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20-24 25-29 30-34 35-36 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Functional limitations in institutions
Functional limitations in HH
Women, late 1990's
3. Estimates based on comparable HH/Institutions survey
In late 1990’s, HID is a HH/Institution based on the French health and disability survey:
-2,8 months
+2,6 months
52,6
52,7
52,8
52,9
53,0
53,1
53,2
53,3
53,4
Sullivan HH/Inst Surv Eurostat
Men. Life expectancy without ADL à 20 ans (prevalence around 3% in HH)
+ 1,1 month
-0,8 month
37,5
37,7
37,9
38,1
38,3
38,5
38,7
38,9
39,1
39,3
39,5
Sullivan HH/Inst Surv Eurostat
Men. Life expectancy without functional limitations à 20 ans(prevalence = 25% in HH)
-4,9 months
+7 months
58,4
58,6
58,8
59,0
59,2
59,4
59,6
59,8
60,0
Sullivan HH/Inst Surv Eurostat
Women. Life expectancy without ADL à 20 ans (prevalence aroud 4% in HH)
-0,6 month + 1,8 month
40,5
40,7
40,9
41,1
41,3
41,5
41,7
41,9
42,1
42,3
42,5
Sullivan HH/Inst Surv Eurostat
Women. Life expectancy without functional limitations à 20 ans(prevalence = 29% in HH)
53,05
53,3
52,8
3. Estimates based on comparable HH/Institutions survey
3. Estimates based on comparable HH/Institutions survey
1. For disability status with low prevalence (ADL), the difference btw HH and Inst are large but the total number of persons concerned is limited: the impact of both assumptions is larger than the confidence interval. Eurostat assumption diverges more than Sullivan, reach a 7 month of HLExp at age 20
2. For disability status with high prevalence (common with age…), the difference btw HH and Inst prevalence reduces with age while % living in institution increases. This inverted trends makes the impact of either assumptions low even if Sullivan is closer to the observation. The differences are within the IC.
Conclusion1. Based only on HH information, population estimates are underestimating the prevalence of
disability. The magnitude of the bias depending on the age patterns of living outside institution and type of disability under consideration.
2. Sullivan assumption seems more accurate but only when statistics allows to focus on health related institutions.
3. But, the variation of the % and type of institutions across Europe prevents from applying Sullivan assumption.
4. In any case, the reality is in between the two assumptions, giving the two limits of a range for the estimates
5. Such approach can be useful to avoid conducting worldwide surveys in institution to better estimate population disability prevalence
0%
5%
10%
15%
20%
25%
>25 25-34 35-44 45-54 55-64 65-74 75-84 85+
Care and nursing home
Care institutions
Institutions for disabled
Religious institutions
Other institution (assistance)
Jails
Residences for immigrants
Other
For students
Residences for children
Italy Men
0%
5%
10%
15%
20%
25%
>25 25-34 35-44 45-54 55-64 65-74 75-84 85+
Care and nursing home
Care institutions
Institutions for disabled
Religious institutions
Other institution (assistance)
Jails
Residences for immigrants
Other
For students
Residences for children
Italy Women
0%
5%
10%
15%
20%
25%
0-14 15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Old ages/Nursing homes
Long term care
Religious communities
For w orkers
Other
Other collective housing
Shelters
Itinerant
For students
France Men
0%
5%
10%
15%
20%
25%
0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Old ages/Nursing homes
Long term care
Religious communities
For w orkers
Other
Other collective housing
Shelters
Itinerant
For students
France Women
0%
5%
10%
15%
20%
25%
30%
0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Home for elderly
Nursing home
Psychiatric Hopsital
Institution for mentallyimpaired
Other institutions
0%
5%
10%
15%
20%
25%
30%
0-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Home for elderly
Nursing home
Psychiatric Hopsital
Institution for mentallyimpaired
Other institutions
1. The European populations living outside HH What is the distribution of the institutions/collective HH in the population
outside HH across Europe? Example with France, Italy and the Netherlands
0
10
20
30
40
50
60
70
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
Yea
rs o
f h
ealt
hy
life
HLY Eurostat
DFLE Sullivan
Men
0
10
20
30
40
50
60
70
France Germany Italy Estonia Finland Austria Cyprus CzechRepublic
Denmark Greece Ireland Hungary Lithuania TheNetherlands
Yea
rs o
f h
ealt
hy
life
HLY
DFLE Sullivan
Women
3. The calculations of HLY: Sullivan vs. Eurostat assumption
At birth
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