Nicolas Berger Herman Van Oyen Assessing cross-national validity of the Global Activity Limitation Indicator (GALI) Nicolas Berger Herman Van Oyen ESRA Conference, 19 July 2013 WIV-ISP Tuesday seminar 26 March 2013 Rue Juliette Wytsmanstraat 14 | 1050 Brussels | Belgium T +32 2 642 51 11| F +32 2 642 50 01| email: nicolas.berger@wiv-isp.be | www.iwiv-isp.be

Outline Background Objective Methods Results Discussion

1. Background

Healthy Life Years (HLY) Life expectancy without disability in daily activities Number of years that one can expect to live at the given age Health state = generic term, many HEs. One of them is HLY, based on activity in daily living, calculation using the GALI. Obtained from annual Survey data (SILC: Statistics of Income and Living Conditions) HLY indicator: used as explanatory variable for working capacities, predict health consumption, mortality GALI DEVELOPPED IN THE CONTEXT OF HE; ONLY HEALTH INDICATOR AT EU LEVEL

The GALI For at least the last 6 months, to what extent have you been limited because of a health problem in activities people usually do? Would you say you have been: Severely limited Limited but not severely Not limited Recall: GALI= GLOBAL ACTIVITY LIMITATION INDICATOR Four conceptual criteria > 6 months of long- standing limitations caused by a general health problem usual activities = activities people usually do severity of limitations is measured (at least 3 levels)

2. Objective

Objective The final objective is to measure the GALI and HLY accurately and in a comparable way. This study investigates national variations in answering behaviours for the GALI in the adult EU population in order to validate and increase understanding of the GALI cross-nationally. GIVEN THE IMPORTANC OF THE GALI FOR HLY, it is important to validate it Past efforts/research: Harmonization of the translation of the EU-SILC question in 2008 Assessment of Reliability and Validity in Belgium (Cox 2009; Van Oyen 2006) Assessment of the Validity in older population in EU (Jagger, 2010)

3. Methods

Approach Association GALI >< other measures of disability Activity of Daily Living (ADL) Instrumental Activity of Daily Living (IADL) Physical functional limitations No gold standard Hypothesis: positive and comparable in all countries Why? In disablement process, there are closely related; (ADL) : (e.g. dressing) (IADL) (e.g. shopping) Physical functional limitations (e.g. walking)

Data European Health Interview Survey Modules implemented in national health surveys English questionnaire (translated according to protocol) Variations: survey method, sampling method, question order Available for 14 countries Adult population Sample size: 1,955 - 35,100 Response rate: 56.0% - 95.5% Participation comp Relevance of meta-analysis : BE, BG, CY, CZ, ES, FR, GR, HU, LV, MT, PL, RO, SI, SK - Institutional population included in BE, CZ and MT - (15 years and older)

Statistical Models Logistic regression (per country) predictors: disability measure, gender, age Random effect meta-analysis NOTE : 1) the GALI was dichotomized (no activity limiation vs. one or more activity limitation) 2) Binary scores and counts of disability were both used to measure the predictors …based on the odds ratios of the logistic regressions to assess the overall effect and heterogeneity between countries

4. Results

Random Effect Meta-Analysis ADL limitations Slovakia excluded dichotomized

Random Effect Meta-Analysis IADL limitations Slovakia and Romania excluded

Random Effect Meta-Analysis Functional limitations

Random Effect Meta-Analysis All odds ratios are significant which confirms the expected association between the GALI and the other disability measures in each country ADL > IADL > Functional Limitations Tests of heterogeneity are significant (P<0.001) : no homogeneous association with the GALI across countries

5. Discussion

Explanations for the differences? Survey effects : administration mode, question order, selection bias Cross-cultural differences predictors: interpretation of « limitations » GALI: different understanding of the question or different response thresholds Lack of harmonization; If it’s a problem with the GALI: then we should increase it’s comparability; maybe modify the question. => more research is needed on the understanding of the GALI & its predictive power (on mortality, on health care consumption)

Thank you for your attention nicolas.berger@wiv-isp.be 19

6. Annex

Variables ADL eating transfer in-, out bed/chair dressing/undressing using toilets bathing/showering Physical functional limitations walking climbing squatting and kneeling carrying in the hands or arms fine hand use biting and chewing IADL preparing meals using the telephone shopping managing medication light housework occasional heavy housework taking care of finances and everyday administrative tasks

Global Model Probability distribution of the GALI against ADL

Global Model Probability distribution of the GALI against IADL

Global Model Probability distribution of the GALI against functional limitations

Global Model Probability distribution of the GALI against other disability measures: stronger association for ADL and IADL GALI is broader than ADL, IADL or Functional Limitation separately Functional limitation does not necessarily lead to GALI