NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Research Council (US) Panel on a Research Agenda and New Data for an Aging World. Preparing for an Aging World: The Case for Cross-National Research. Washington (DC): National Academies Press (US); 2001.
As the length of life and number and proportion of older persons increase in most industrialized and many developing nations, a central question is whether this population aging will be accompanied by sustained or improved health, an improving quality of life, and sufficient social and economic resources. The answer to this question lies partly in the ability of families and communities, as well as modern social, political, economic, and health service delivery systems, to provide optimal support to older persons. However, while all modern societies are committed to providing health and social services to their citizens, these systems are always in flux, guided by diverse and evolving national and regional policy formulations. Health, social, and economic policies for older persons vary substantially among industrialized nations. Analysis of these variations through appropriate cross-national research may assist greatly in the formulation of effective policies aimed at enhancing the health status, as well as the social and economic well-being, of elderly populations.
Among the most important policy concerns relevant to health and longevity are the future fiscal viability of pension, health, and social insurance systems, both public and private, and the implications of these systems for savings and investment rates (see Chapter 3). How long people continue working, paying taxes, and saving will feature prominently in the consequences of population aging. Many people already work less than half a lifetime because of extended periods of schooling and training in early life, earlier retirement, and enhanced longevity, posing a challenge to the sustainability of systems designed to support older persons. If the trend toward increased longevity continues without a parallel extension in working life, the stress on these systems could be even greater.
As discussed elsewhere in this volume, labor force participation, investment and saving behavior, and provision of health services are complex phenomena that are interrelated at both the individual and societal levels (Quinn and Burkhauser, 1994; Smith, 1999). For example, incentives provided by government and employers play important roles in determining labor force participation. Reducing the implicit tax on continuing work beyond the normal age of retirement and reducing the costs of hiring (and possibly retraining) older workers have the potential to encourage longer working lives (see Chapter 3). Yet in designing such incentives, policy makers need to know how long they can reasonably expect people to keep working. Just how physically and mentally capable are older people? What is the trajectory of health and function as people age? Can their productivity be maintained and enhanced at older ages, and at what cost? Does the type of productivity and engagement change with age? How can health care services be provided in such a manner as to maintain optimal health and function? Most basically, policy makers must make difficult decisions about the allocation of limited resources to preserving and improving health. How is good health achieved at a reasonable cost? Should more resources be directed toward behavioral change and other health promotion and disease prevention programs, including health enhancement in early life, or should more be dedicated to the treatment of patients with advanced diseases? How much should be invested in the development of new health care technologies, service delivery enhancements, and professional training?
A focus on national-level health status and its temporal trajectory is critical for several reasons. Health status is one of the most important indicators of well-being, and it predicts a large proportion of societal expenditures on health and social services for the elderly. Health status is also reciprocally affected by social and political policies and programs. Further, health status is malleable through high-quality health promotion and disease prevention programs, as well as effective medical services. National programs and policies that may appear to be devoted to health and health services for older persons often have important implications for and complex interactions with other economic sectors. Table 6-1 provides examples.
Relationship of Public-Sector Programs and Policies to Health Services for Older Persons.
This chapter is devoted to the centrality of health status and change in informing health, social, and economic policy formulation. We first outline the key issues to be addressed by research on the health status of the elderly. We then present a conceptual model of the determinants of health status to provide a framework for the ensuing discussion. Next we review the basic measures of health status, presenting selected examples of basic international patterns and trends. This is followed by a brief look at the characteristics of national health systems. Data sources for cross-national research on the health status of the elderly are then considered, as well as the pitfalls and strengths of such research. Finally, we offer recommendations for strengthening research in this domain.
National health policy decisions with respect to older persons are becoming increasingly complex for several reasons. As noted in Chapter 2, the numbers of the elderly and oldest old have increased dramatically in most industrialized nations. Countries that already have a substantial elderly population face increasing proportions in the coming decades, with all the accompanying social and economic demands. In addition, nations must prepare for the growing numbers of disabled younger persons who are now surviving to older ages because of improved health care. Policy decisions related to the provision of health services for the elderly have become complex from technological, fiscal, and ethical perspectives. Also, as noted above, health services are intimately tied to the provision of social services and economic support, including housing, nutrition, institutional care, and related activities. Preventive and rehabilitative services have added not only to the costs of care, but also to the potential for improved function, mobility, and social engagement. Health care for older persons is thus different from that provided to other age groups in several respects: greater resource demands; the intertwining of professional health services with social services; the frequent occurrence of important ethical conundrums; a higher prevalence of physical and mental disabilities; and, perhaps not as obvious in policy formulation, less scientific evidence for use in determining effective preventive and medical interventions. In this context, the following issues merit special emphasis.
What is the importance of health status for retirement preferences and patterns? How are health status and retirement age related? Have recent trends in reduced age-specific rates of disability translated into increased and longer labor force participation?
What impact does health have on families? How has the changing health status of older persons altered the productivity and economic status of families and households? How do families make economic provisions to care for unhealthy parents, and what are the effects on labor force participation? How does the changing health status of older persons, in particular the onset of infirmity, affect the capacity to be a caregiver for an ill or disabled spouse or other family member? What economic provisions do families make for long-term care of older persons, whether in the community or within chronic care institutions? How do these provisions dovetail with public and voluntary assistance and care programs?
How important is health to wealth and economic status? What evidence is there that health status directly affects individual wealth, assets, and economic productivity? What is the role of the health care system in the prevention, treatment, and rehabilitation of illnesses, and how does this work to maintain personal economic status? How do health shocks affect future economic status and personal and family wealth in accordance with underlying socioeconomic status?
How do economic status and educational levels affect the health of individuals across the life course? By what mechanisms and to what degree does economic status lead to better health status? At what ages do the effects of economic status have the greatest impact on health status? How does the distribution of wealth, income, and economic productivity within a nation serve to preserve, enhance, or depress health status independently of individual and family socioeconomic characteristics? How does the provision of health services affect long-term health outcomes?
The formulation of health service delivery policies and systems for older persons requires a continuing flow of information, including quantitative data on the above and other issues related to population health status and directions, as well as the resources expended in the health care system. In particular, the ability to draw on international experiences in health and health care can greatly enhance the potential of such policies and systems. Moreover, cross-national research can enable the creation of evaluative mechanisms that would often not be feasible in any one country because of the homogeneity of medical practices and administrative cultures. Such research can also help address the above issues by providing a range of observations of change over time and, perhaps, early indications of emerging health trends. And comparative work can improve our understanding of how particular diseases and conditions are expressed as disability in a variety of work, social, policy, and living environments, thus providing insight into which adjustments in those environments may be most cost-effective.
As noted above, the determinants of health are complex and comprise multiple policy domains. One basic but important conceptual model that can be used to illustrate the breadth of these determinants is shown in Figure 6-1. This construct represents the health of all demographic groups in a society, although the emphasis here is on the health of older persons. The determinants are presented in a set of concentric circles, with the community population at the center. Outermost, and often difficult to quantify, are the general social, economic, cultural, and environmental (physical-chemical) conditions that have important long-term health effects. The next circle contains society's basic social, health, and economic institutions, which sustain or impair a healthy existence. The next circle emphasizes the critical role of social and community interactions and exchanges, whereby individuals make their collective decisions. The circle next to the core highlights the importance of individual behavioral choices (e.g., cigarette smoking, risk-taking behaviors) in the determination of health status.
A conceptual framework for determinants of health status. SOURCE: Dahlgren and Whitehead (1991). Reprinted with permission.
One drawback of a two-dimensional representation is the absence of time. Other models highlight more fully such issues as the role of infancy and childhood and the environment on health outcomes in later life. Nevertheless, the model in Figure 6-1 is useful in many respects. For example, it highlights the intimate interaction between the economic and employment environments and health discussed above (see Annex 6-1 for a specific policy example). As a corollary, the model places the role of professional health services in an important but not dominant role among the institutional forces that mediate health status. The model quite appropriately also emphasizes the role of basic public health determinants, such as the physiochemical environment and the provision of safe and adequate food and sanitary services. In addition, the model reflects an appreciation of individual responsibility for health status, both in the selection of behaviors and in the collective decisions made by individuals. Finally, the model shows that policy interventions in one institution or domain may or may not have the desired effect because of the multiple sectors involved. Thus, policy outcomes may be enhanced only through multiple intervention points; conversely, interventions in one sector may have unpredicted outcomes in others.
During the 20th century there were great changes in patterns of population health status and survivorship in both the industrialized and developing worlds. Among industrialized nations, the early part of the century saw the greatest improvement in mortality among infants, children, and pregnant women. These improvements continue to the present time. Later in the century, however, substantial reductions in mortality among older adults occurred in nearly all developed countries as a result of declines in deaths primarily from heart disease, but also from other major causes. Moreover, there has been a shift among older persons to surviving, and even thriving, with prevalent chronic illnesses such as various heart conditions and arthritis. Population surveys have also indicated that the age-specific prevalence of physical disability has declined in some countries (Jacobzone et al., 1998). Developing countries have lagged behind their more industrialized counterparts in terms of mortality decline and the overall epidemiological transition from a preponderance of infectious and parasitic diseases to one of chronic and degenerative diseases. As noted in Chapter 2, however, the overall gap between more and less developed countries has narrowed considerably.
The last third of the 20th century also saw a significant expansion in the ways population health status can be characterized, particularly by supplementing mortality data with emerging measures of personal clinical signs and symptoms, diseases and conditions, and functional disabilities. The potential availability of more specific types of health data has greatly increased the set of quantitative tools for health policy and planning, particularly as regards older persons, whose rates of disease and disability are higher than those of other demographic groups.
Identifying the trajectories of important health measures is central to forecasting health care needs and generating policies for older persons. Yet, defining “health” and the health status of individuals is not an easy matter. Even under optimal circumstances and without resource constraints, it is challenging to fully assess the physiological state of individuals, to understand the nature and determinants of personal or social behavior, and to predict the range and intensity of the outcomes of environmental challenges (e.g., from the workplace or elsewhere in the community). Nor is it easy to predict what effects various medical services or interventions will have on individuals. With the newer and more precise measures of health status now available, however, much can be accomplished.
Health status can be characterized from varying perspectives depending on the goals and uses of the information. For example, personal health can be assessed by subjective self-report, more objective physiological and biochemical measurement, or standardized indicators of diseases and disabilities present. In fact, all of these perspectives are important and complementary. Further, health status may be characterized according to major domains such as physical health (e.g., the function of the heart and lungs), mental health (e.g., the presence of depressed mood), and physical and social functional health (e.g., the ability to climb stairs or work at a particular occupation). Health may also be thought of in its temporal, longitudinal dimensions. For example, how is health status changing, or did an individual live or die? Changes in health status may be reflected as well in the intensity of health care resource utilization, such as pharmaceutical, institutional, or rehabilitative care. This temporal perspective is critical and leads to an emphasis on longitudinal, cohort data sources.
While there are no wholly standardized approaches to characterizing health status, there are several meaningful ways in which individual health is assessed and described. These data may not be available from many areas in a computerized or otherwise readily retrievable format, but can usually be obtained by abstracting clinical records or surveying patients, health professionals, administrators, and/or populations within a geographic area. Annex 6-2 describes in detail the health status measures most commonly used for survey and administrative data collection in the categories of clinical signs, symptoms, and syndromes; morbidity (i.e., discretely defined medical conditions); self-rated health; functional status and disability; physiological and pathological measures; mortality data and derived measures; and aging and mental illness.
As noted in the model of health determinants discussed above, both personal behaviors and many public health measures bear on health status. Health promotional activities aimed at older persons may or may not involve direct contact with the formal health care system; examples of the latter activities include education programs and provision of good preventive nutrition, safe transportation to enhance mobility, and assurance of adequate housing. Thus the efficacy and net impact of many basic public health programs, with their incumbent costs, can be assessed only by using population survey information in addition to the data derived from clinical sources. Moreover, decreased use of toxic substances and increased exercise and structured leisure activities, and even paid and unpaid work, are associated with enhanced function, decreased occurrence of physical and emotional illness, and higher quality of life among older adults. Effective national and regional policies for health promotion among older persons therefore require that important deficits in these areas be identified. Population surveys may be the only means of acquiring accurate information on such issues as cigarette and alcohol consumption, perceived elder abuse, the availability and use of exercise and other leisure and recreational programs, and levels of mobility and social interaction.
Also central to national health policy for older persons is the ability to provide community-based preventive services, generally delivered in the context of primary care. The presence of such services has been used in the United States and elsewhere as a benchmark of the general quality of care (Bloom et al., 2000). Included are such activities as provision of appropriate immunizations and screening for early and treatable conditions, such as colon and breast cancer, high blood cholesterol, high blood pressure, and depression. Explicit geriatric screening and management programs are recommended for falls, early cognitive impairment, physical disability, and inappropriate use of medication. Provision of these services leads to a higher quality of life and helps maintain or enhance function in the elderly. Even in the presence of overt illness, a systematic approach to the complex functional and medical problems of older persons, often referred to as geriatric assessment, can help maintain useful function. Some preventive activities may be recommended by health professionals but executed by others. An important example is environmental screening of residences to prevent falls and enhance mobility, such as by providing ramps rather than stairs and handrails at appropriate locations.
Coordination of public and clinical policies relevant to health promotion and disease prevention among the various sectors involved is essential if these policies are to have the desired positive effects on the health status of older persons. International comparisons of preventive service delivery programs may help identify those with the most desired outcomes and indicate which individual programs may be applied usefully in many nations. For example, standardized specific blood cholesterol levels predict very different heart disease rates in different countries (Kromhout, 1999), possibly leading to different priorities for prevention programs. Again, the most effective means of obtaining the information necessary for such cross-national research is representative household surveys of older persons.
All national health systems are extremely complex in structure, function, and administration. This complexity and diversity makes their classification difficult, a difficulty that is exacerbated by the fact that all health systems are constantly evolving in accordance with ongoing political and economic forces. This complexity also makes policy initiation and assessment, regardless of how broadly construed, extremely challenging. At the same time, however, most modern health care systems, particularly within developed countries, face common forces and challenges: rapid and costly technological innovation; the increasing infusion of business practices to contain the costs of delivering care; growing consumer demands for care that is uniformly distributed geographically and socioeconomically; the provision of effective quality assurance programs; the need to identify funding for the breadth of health services demanded by communities, to balance the needs of primary and specialty care programs, and to respond to complementary and alternative medical practices; and, in many cases, the decentralization of authority in previously monolithic systems.
A variety of classification systems have been proposed and applied in the comparative study of health systems, but no generally accepted taxonomy has emerged. A broad range of health system typologies is reviewed by Mechanic and Rochefort (1996); these typologies variously emphasize such dimensions as political organization and control, economics and fiscal management, population demands and utilization, the role of market forces, universality of coverage, cultural influences on professional practice, the degree of professional dominance, and adherence to various social movements and principles.
Because of the higher rates of morbidity and disability that occur with increasing age, older people make substantial use of formal health services. Such services consume an enormous amount of resources, and a central policy issue for all countries is how to expend available resources in a way that will yield the best health outcomes feasible by the most efficient means. Again, cross-national comparative research is one important avenue for addressing this issue by examining international variations in organization, financing, delivery, and evaluation of elder health services. To illustrate, Figure 6-2 highlights the international variation in per capita nursing home utilization across 20 countries, and Figure 6-3 shows variation in spending for health services across the G7 nations. One of the most important macroanalytical policy questions is the relationship of health system organization, administration, and financing to health status and outcomes. Little work has been done in this area, but cross-national analyses offer the best approach to understanding how major components, such as the level of investment in new technology, affect health outcomes.
Percent of elderly population in residential care: Circa 1991. SOURCE: Organization for Economic Co-Operation and Development (1996).
Medical spending in the G7 countries: 1990. SOURCE: Cutler (1999).
There are many units of analysis for characterizing health systems, depending on the issues being addressed. Table 6-2 lists examples of analytic variables commonly used to describe health systems at either the national or regional level. These variables involve a substantial amount of conceptual complexity, and several issues should be considered when using them. As noted earlier, health status is determined only in part by the units of health service delivered. Health systems offer numerous preventive care and public health services in ways that are difficult to quantify. In all age groups, but particularly among older persons, there is a substantial amount of self-care, as well as varying levels of alternative and complementary health care practices, including self-medication with herbs and the use of alternative practitioners, that may have an impact on health outcomes. Further, both preventive and clinical care may impact health outcomes and quality of life only in future decades, and this latency may be difficult to assess in analytical studies. In fact, many of the fundamental professional activities of health systems may be critically important to patients and their families, but would not be expected to result in objective, quantitative health outcomes; examples include ensuring that illness is not present, providing prognostic information, assisting with care administration issues, and delivering family-friendly hospice care. Despite these conceptual challenges, however, cross-national studies offer the best opportunity to determine how various health system structures and funding and management mechanisms affect health outcomes.
Selected Units of Analysis for Characterizing Health Systems.
Regardless of how sophisticated, modern, and comprehensive health services may be in a nation, utilization of those services is often uneven and may vary by socioeconomic status, ethnicity, geographic location, and many other factors. Equally important, there may be selective factors related to illness characteristics and personality among individuals that dictate special behaviors within the health system, confounding the study of health outcomes. Moreover, all health care systems have adverse effects, which can diminish the net positive effects of health outcomes. Common examples include hospital-acquired infections, misapplication of therapies, and the unintended adverse effects of medications and devices. It is important to identify these adverse effects, as many are remediable. Finally, there is variation within national health systems in the quality of care and quality assurance programs. For example, substantial small-area variation in medical/surgical procedure utilization rates and health outcomes has been demonstrated within many modern health systems. In addition, some services may be less sophisticated in rural or frontier areas or in other geographical locations. This variation highlights the need for comprehensive, large-area or national data with which to conduct suitable research.
The data required to conduct cross-national research on the health status of the elderly may come from many sources, and it is not always possible to anticipate in advance what variables will be needed. Moreover, elderly populations have a number of special characteristics that make their health data needs different from those of other groups:
Health events on average occur at a more rapid rate among the elderly than in other age groups, increasing the need for longitudinal (panel) data on cohorts of elders.
Older persons have many clinical signs, symptoms, and functional impairments that need to be given special attention since they are not included within traditional administrative data systems that focus on morbidity.
Since older persons commonly have multiple medical conditions and functional impairments, there is a need to develop summary measures of comorbidity and health status in order to deal efficiently with the available health and administrative data. Considering the conditions and impairments of the elderly in isolation will, in some instances, impede global policy development.
Successful health service delivery for older persons benefits from data on their physical and social environments. Knowledge of the social environment is critical for the large number of elders who have limitations in mobility or self-care; it is also essential for ensuring that prescribed medical regimens are delivered correctly in both home and community settings. Data on the physical environment are important as well for minimizing falls, injuries, and the progression of disability and, in some cases, for preventing deaths from climate-related causes.
Cognitive and mental impairments are common among the elderly, particularly among the oldest old. Such impairments can lead to a lack of social support and interchange, failure to follow medical treatment plans, inability to perform self-care, and increased need for structured supervision and institutionalization. Thus, acquisition of data on the population occurrence and correlates of mental impairments becomes critical for shaping elder health and health care policy. Because some of these impairments preclude direct interviewing of those involved, techniques for acquiring proxy data are necessary.
Compared with other age groups, older persons have much higher rates of institutional residence and use of long-term care services in the home and community. A comprehensive national population perspective on this large and growing group requires data on the health status of these persons and the nature of the long-term and institutional care being provided.
The remainder of this section reviews the various sources of health data on the elderly, along with ways in which these data could be made more useful for cross-national research and policy formulation.
A broad range of data on health and health status is available in most developed nations and increasingly in developing nations as well. These data must be approached cautiously and their limitations recognized. Table 6-3 (adapted from Andrews, 1999) summarizes health data sources and their potential limitations.
Sources of Health Data and Their Potential Limitations.
As Table 6-3 illustrates, a number of barriers may exist to the successful application of these potentially rich data sources. First, in many instances there may simply be insufficient or inappropriate data gathered or available, and the data collected may be of limited accuracy. There is also little standardization in the collection and representation of administrative data across nations, a limitation that may extend to computer software and formats. Information may not be available in a timely manner, often being delayed by several years. Policy and decision makers may misunderstand the relevance of information for research applications, and those conducting research studies and surveys may misunderstand the policy process, although the imposition of political perspectives on the conduct of research may be detrimental to all. Political, fiscal, and ethical considerations may not permit easy distribution of the data to appropriate analysts. Finally, there may be inadequate analytical methodology to summarize and interpret complex and large datasets. Thus concerted administrative and political effort is required to collect the data necessary to exploit the opportunities of cross-national research.
Availability and access are key limitations for many of the health data sources listed in Table 6-3. While some datasets will inevitably have limited distribution, others would be usefully provided in repositories or catalogued for administrative and research analysts. No single central repository now exists for health information from population surveys or health system administrative data relevant to older persons. Important catalogues are being compiled, however, by such organizations as the United Nations (Agree and Myers, 1998), the Organization for Economic Cooperation and Development (OECD) (Gudex and Lafortune, 2000), the European Union (Hupkens, 1997), and the U.S. National Institute on Aging (2000). In addition, the Interuniversity Consortium for Political and Social Research at the University of Michigan operates a National Archive of Computerized Data on Aging (HtmlResAnchor http://www.icpsr.umich.edu/NACDA/index.html) that is increasingly international in scope. The efforts of these organizations will continue to be important in identifying the data needed for cross-national research.
The diverse practical needs of health care organizations and agencies that address aging issues, both within and among nations, pose a challenge to achieving the data comparability required to answer many fundamental questions that transcend local populations. Each unit builds administrative data systems and collects data consistent with its unique needs and perceptions of utility. A common problem that results is loss of the capacity to gain analytical power by comparing local experiences with those in other populations or regions.
National governments may deal with this issue by developing minimum and/or core datasets with precise definitions for each data element. Doing so enables common approaches to data reporting on vital and health statistics and to analysis across population groups, elements of service systems, and utilization and costs of care. In the United States, the National Center for Health Statistics, working with other agencies in the Department of Health and Human Services and with the advice of the National Committee on Vital and Health Statistics, establishes minimum datasets, data elements, and data definitions used uniformly throughout the Department of Health and Human Services. While these activities contribute importantly to common nomenclatures and data standards, special data repositories are needed for information thus collected in developed and, where possible, developing countries. The World Health Organization has worked and continues to work toward this end.
Most countries continue to standardize the vocabulary of health services administration. For example, the United States is moving toward a standard long-term care dataset with the following categories: demographic items, health status items, service items, and procedural items. Demographic items include sex, birth date, race, ethnicity, marital status, usual living arrangements (type and location), and court-ordered constraints if any. Such a list could be expanded substantially (for example, to include educational level attained, income from various sources, entitlements received, and religion and religious participation). The list can be altered in response to political, social, or economic forces, as well as agreed-upon international nomenclature where possible.
Variations in data collection across countries greatly compound the difficulties of obtaining comparable information. Even small variations in definition, question formulation, and mode of data collection may significantly alter responses and impair comparability. Moreover, understanding and interpretation of data elements may vary among cultural settings. It is essential to facilitate valid comparisons by easing the data collection burden on countries and regions that have many fewer information gathering resources than the richest Western countries, and by providing a basis for meaningful national comparisons across surveys, administrative data systems, and other sources of health and aging data.
The concept of the graduated minimum dataset could be applied to facilitate health research and policy analysis relevant to aging by providing basic descriptive data on individuals, disease and disability measures, long-term care programs and facilities, health service utilization, and related data elements. Since all nations cannot be expected to invest the same level of resources in data collection, a hierarchy of data collection modules, ranging from easily collected basic data elements to increasingly elaborate datasets, would be an appropriate universal approach. Such a hierarchy might have five to ten levels—from a bare minimum of descriptive statistics to rich and comprehensive data elements such as those found in the Health and Retirement Survey and the Medicare Current Beneficiary Survey. Each such level would have clear definitions of elements, precise wording, and defined response categories. The choice of data elements would be supported by reliability and validity studies justifying their inclusion. Any administrative authority could decide how extensive its data collection would be, but whatever the level selected, the data collected could be made comparable to those from other collection efforts. The value of such a system is that the administrative authority could add any data items needed to meet local purposes without undermining the comparability of the data collection efforts across geographic units. A feasibility study of a small number of aging-related measures, such as those related to disability, could be conducted to test this approach and assess the implementation issues that need to be resolved.
Assessing the health of older persons requires the compilation of data from many sources, such as personal and family surveys, vital records, health care administrative records from various providers, and other health-relevant sectors of society. Moreover, since multiple conditions and impairments are common among older persons, they may seek medical and social services from a variety of providers. The value of data linkage for improved policy formulation has been well-documented (National Research Council, 1988). The use of primary institutional records increases the accuracy of the information available for analysis and complements information that can be gained only from interviews. At the same time, however, there are several potential impediments to record linkage, including costs, privacy concerns, and the logistics of assembling data from multiple sources.
As noted earlier, cross-national comparisons can be useful in a number of ways in addressing issues related to the health status of elderly populations. A cross-national perspective encompasses a broad range of variations that can yield important qualitative insights into alternative institutional arrangements, policies, and programmatic interventions not available for study in one country. Cross-national comparisons can also provide some sense of the generalizability of observations made in specific national and cultural contexts. To the extent that similar patterns and trends are observed across nations that vary in social structure and culture, as well as in health and welfare approaches, one can have greater confidence that generalizations formulated have merit. Box 6-1 provides an example of how a key issue—deinstitutionalization of elders—could be illuminated by cross-national research.
Deinstitutionalization of Elders. With continuing increases in longevity, many more people are surviving to advanced ages, when the prevalence of chronic illness and disability increases significantly. In the past, persons surviving with substantial disabilities (more. )
At the same time, one must recognize the complexity involved in comparing national health systems with varying histories, organizational arrangements, cultural influences, and statistical systems. It is essential that when making such comparisons, the analyst understand thoroughly the contexts being compared and the special measurement, definitional, and linguistic features of each system to ensure that comparable units are being evaluated. Even apparently simple concepts can be difficult to compare across systems. As an example, physicians have varying functions in different national health care systems. General practitioners in the United Kingdom and other European nations, for instance, are exclusively community practitioners, while in the United States they typically provide some amount of in-patient and institutional care.
In addition to cultural variations, there are many factors that may limit or confound cross-national research and must be considered to maximize the credibility of the findings of such studies. For example, underlying population health status may vary across nations; this variation may lead to different outcomes of the same health policy or intervention. There may also be differences in the nature, selection, representativeness, or completeness of population samples and health administration databases, possibly leading to spurious analytic findings. Variation in the accuracy and completeness of clinical and vital records information can confound cross-national comparisons as well. Concepts of health states, individual diseases and conditions, and disability may likewise vary across nations and cultures, and such variations may not be fully captured using international disease coding systems. Differences in styles of clinical practice and healer-patient interaction and in the use of alternative practitioners may preclude full comparability of summary diagnostic information. And variations in health service organizational modes, financing, and budgeting may make it difficult to capture resource levels or allocations for comparable units of service delivery. Given these variations, the failure to find certain effects of national health systems on a particular health or programmatic outcome may be due to the noncomparability of the study units as well as to the possibility that no effect is actually present.
At the same time, there clearly is increased comparability among nations in the clinical/administrative and survey data being collected. In the future, cross-national research is likely to be facilitated by increased international exchange of scientific information, as well as by advances in survey instruments and measurement techniques; health care evaluation methodology; clinical training and achievement norms; database computerization and management; and regulatory standards for drugs, devices, and other medical interventions. These advances will be enhanced by the growth of international companies and industries that address the provision of clinical services in many parts of the world.
Designers of government-sponsored nationwide surveys should enhance basic health information on older persons and strengthen the foundation for standardized measures that can be applied to cross-national comparisons. Health status information on older persons should, at a minimum, include the frequency and rates for (1) deaths and their major causes; (2) important acute and chronic medical conditions and their major manifestations; (3) measures of important self-reported health status; (4) population levels of physical, social, and mental function; (5) preventive and health promotional behaviors; and (6) important disabilities. In addition, minimum health care information for older persons should include (1) utilization rates for important types of health services, including institutional and home-based care; (2) personal and family expenses for formal health services; (3) rates of use of medications and devices; (4) major cultural influences on the concept of health and the use of health services (such as gender, ethnicity, geographic residence, and socioeconomic status); and (5) the use of informal and alternative and complementary health care services, including self-care practices and assistance from families and other nonprofessional sources.
The concept of a graduated minimum dataset should be implemented as a means of facilitating health research and policy analysis relevant to aging populations. To provide basic descriptive data on individuals, disease and disability measures, long-term care programs and facilities, and health service utilization, countries should adopt systematic data collection procedures. All nations cannot invest the same level of resources in data collection; thus a hierarchy of data collection modules ranging from easily collected basic data elements to increasingly elaborate datasets would be an appropriate universal approach. Such a hierarchy might have five to ten levels—from a bare minimum of descriptive statistics to rich and comprehensive data elements such as those found in certain OECD countries.
All countries should facilitate the linkage of population-based and administrative health information with other important economic, social, and health service data. Despite logistical and other challenges, linking population survey data to medical, vital, and administrative records, as well as other social and economic data sources, can expand the value of the data for determining population health status and conducting programmatic and policy planning and evaluation (e.g., for assessing levels and changes in disability rates, estimating the effects of insurance coverage on health system expenditures, and providing supplementary information on medical program functions).
Longitudinal data on the health of older persons should be collected to enable identification of the risk factors, causes, and preventive interventions for disease and disability. Panel (cohort) studies should also include economic, behavioral, and social domains to make it possible to identify those groups and individuals at special risk for illness and their respective consumption of health care resources, and to determine whether health outcomes differ according to variations in health care interventions, programs, and policies.
Cross-national panel studies should be used to clarify the relationship between health system organization, administration, and financing on the one hand, and health status and outcomes on the other. Data from longitudinal, population-based surveys, linked to administrative records and with comparable questions across countries, are essential in comparing health across countries and attributing changes in health to particular factors. Moreover, comparative work can improve our understanding of how particular diseases and conditions are expressed as disability in a variety of family, social, and residential environments, thus providing insight into which policies and interventions are most efficacious.
In all societies, health and functioning vary according to socioeconomic position. The magnitude of these differences and their causes vary over time both within and among societies. To develop policies that can effectively ameliorate these differences requires an understanding of their causes. Policy responses to socioeconomic differentials in health and functioning will ideally cover a wide range of determinants, including medical care and social services. There are likely to be socioeconomic differences in the provision of, access to, and response to these services.
Social inequalities in health affect older as well as younger people. Annex Figure 6-1 shows mortality by employment grade among British civil servants who were part of the first Whitehall study (Marmot and Shipley, 1996). The figure shows clearly that mortality rates follow a social gradient. The implication for monitoring and for policy is that this is not a clear case of poor health among those who are materially deprived and better health for everyone else; the social gradient in health runs the social gamut from top to bottom. While Annex Figure 6-1 is confined to mortality, social inequalities in morbidity loom large among the elderly, and the implications for policy are perhaps even more challenging here. A particular problem in many industrialized countries is the large numbers of elderly women living alone and hampered by disability. Their situation is worsened by factors related to social position, with implications discussed below.
Relative mortality (all causes) by grade of employment, Whitehall men, 25-year follow-up. SOURCE: Marmot and Shipley (1996).
Annex Figure 6-1 also shows that the relative difference in mortality from top to bottom is less at older than at younger ages. This raises two further issues: the appropriate measure of disease burden and the appropriate measure of social classification. Although the relative difference in mortality may be less at older ages, the absolute difference is greater because overall mortality rates are higher. Although relative differences are usually taken as a guide to the strength of causal factors, absolute differences are a better indicator of the social importance of the total burden of disease and suffering.
Some countries have had a long tradition of measuring socioeconomic position. The theoretical basis for the various measures that have been used is sometimes explicit, more often implicit, and sometimes nonexistent. Measures based on education, income, occupation, or some combination of these are commonplace and often atheoretical. It has been argued that a sounder theoretical basis for socioeconomic classification would yield better understanding of the determinants involved. One approach to this end is to conceive of three different modes of social stratification: one based on degree of material deprivation, one based on social power relations, and one based on general social standing (Bartley and Marmot, 2000).
Measures of material deprivation are appropriate for assessing health differences among those living under conditions of absolute poverty. Such measures are less appropriate where health follows a social gradient, such as in the Whitehall studies (Marmot and Shipley, 1996; Marmot et al., 1991). In such cases there are clear social inequalities in health among people who are not materially deprived. Other concepts must therefore come into play. A second approach that does potentially relate to the whole social gradient is based on power relations in the workplace. Occupations are defined in terms of power and autonomy, a perspective that has its origins in the Marxist concept of class. This approach is the basis for the Eriksson-Goldthorpe scheme, which in turn provided the framework for the new British socioeconomic classification that will be used nationally for the 2001 census. A third approach, that of general social standing, has features in common with Weber's concept of status, based on patterns of consumption and lifestyle. The status group shares the same level of prestige or esteem and, in addition to common forms of consumption and lifestyle, limits its interactions with members of other groups.
It is impossible to give a blanket prescription for the most appropriate measures of socioeconomic position in different cultures. As measures are developed and applied, it would be valuable to attempt to relate them to theoretical concepts such as the three sketched above.
A measure that is appropriate for social classification among people of working age may be less appropriate for those beyond working age. In many countries, occupation is used as a basis for social classification. There is ample justification for this approach in that work is central to peoples' lives (Marmot and Feeney, 1996). Occupation is a major determinant of income, which in turn affects life chances. Also, the work career is an important part of socialization and achievement of social identity outside the family. It offers opportunities for both fulfillment and frustration of life's goals. Self-esteem, social approval, personal attitudes, and behavioral patterns are all influenced by occupational level. Finally, occupation itself and conditions in the workplace may be important determinants of social inequalities in health.
The degree to which occupation continues to provide a reliable indicator of these four elements in people beyond working age will vary. Additional methods of social classification will be needed. This will especially be the case for older women, particularly those single, widowed, or divorced. Other socioeconomic measures that have been used include education; income; housing tenure; characteristics of area of residence; and, in Britain, household access to a car. The issue of appropriate classification bears on the question of why social inequalities in health may be of lesser magnitude in women than in men. In the past, the social status of married women was better defined by their husband's occupation than by their own. While this situation may still obtain in some circumstances and populations, it is being challenged by dramatic social changes (Bartley et al., 1999). Close attention must be paid to the most appropriate measures that will allow comparison of social inequalities in health within and between genders.
Any feature of social or personal life, of biology, and of services may influence social inequalities in health. At the request of the World Health Organization, the International Center for Health and Society at University College London organized research findings on the social determinants of health under 10 headings (Wilkinson and Marmot, 1998).
