BMJ  2004;329:767 (2 October), doi:10.1136/bmj.38202.667130.55 (published 17 September 2004)

Paper

Life span and disability: a cross sectional comparison of Russian and Swedish community based data

¹ International Centre for Health and Society, University College London, London WC1E 6BT, ² Department of Health and Society, Faculty of Health Sciences, University of Linköping, Sweden S-58183

Abstract

Objectives To compare levels of disability (in terms of physical function and self rated health) among middle aged and elderly people in Russia and Sweden, a country with high life expectancy.

Design Cross sectional study.

Setting General population of the Russian Federation and of two counties in southern Sweden.

Participants Randomly selected men and women in Sweden (n = 9489) and Russia (n = 1599).

Main outcome measures Official life table data; self rated health and physical functioning (subscale of the SF-36).

Results The official life table data showed large differences in mortality—for example, 36% of Russian men aged 45-49 years would survive the next 25 years compared with 75% of Swedish men. The survey data showed, for both sexes, similar levels of self rated health and physical functioning in the two countries up to the age of about 45 years, but after that, the age related decline in both outcomes was much faster in Russia than in Sweden. By combining the national life tables with survey data on physical functioning we estimated that in the age group 45-49 years, 99% of Russian and 97% of Swedish men would be free of disability; of these, if these data were for a cohort, only 17% of Russians would be alive and free of disability 25 years later compared with 65% of Swedes. The difference in survival was similar in women.

Conclusions Large differences exist in survival without disability between elderly Russians and Swedes. The short life span in Russia reflects high levels of ill health and disability and is associated with a rapid age related decline in physical functioning.

Introduction

Life expectancy in Russia is considerably lower than in western Europe.^{1 2} Some of the excess mortality is due to injuries, violence, and alcohol misuse,^{1 2} but the high mortality in Russia persists into older age groups, where these causes of death are much less common. So far, data on rates of non-fatal outcomes in Russia have been available for cardiovascular diseases^{3 4} but not for health conditions specific to elderly people, such as impaired functioning or disability. Such information is important to assess the rates of ill health in elderly people, which pose a heavy burden for health and social services.

We compared data on self rated health and physical functioning in community based population samples in Russia and southern Sweden to examine whether the high mortality in Russia is reflected in poor health among elderly people, and, if so, what are the implications for survival without disability.

Methods

Sources of data
We used official life tables for Russia and Sweden in 1996.⁵ Data on self rated health and physical functioning were taken from cross sectional surveys in random population samples.

The Russian data came from the 1996 New Russia Barometer (NRB) survey of a random sample of people aged 18 years selected in a multi-stage sampling process (see bmj.com).⁶ The participants completed an interview that covered a wide range of sociodemographic variables, attitudes towards the political and economic changes, and self rated health and physical functioning. The 1599 completed interviews represent a final response rate of 66%.

In 1999 a random population sample completed a postal population survey in two counties in southern Sweden: Östergötland and Kalmar. After the exclusion of incomplete questionnaires, 9489 people were included in the following analyses (response rate 59%). The survey included a wide range of questions on sociodemographic and lifestyle characteristics and health.

Health variables
Both countries used identical questions on health. Self rated health was assessed by the question "How do you rate your health in general?" with responses on a 5 point scale. We combined the two lowest categories ("bad" and "very bad") into "poor health" in our analysis. Physical functioning was measured by 10 questions included in the SF-36.^{7 8} The questions cover limitations in several everyday activities (for example, shopping, bathing, walking). We used a standard algorithm to calculate an overall physical functioning score with values from 0 (total disability) to 100 (full functioning); "low physical functioning" was defined as a score less than 60.

Results

The official life tables showed that mortality in those aged < 45 years was much higher in Russia than in Sweden. In Russia, 80% of males and 93% of females survived from birth to age 45 years compared with 97% and 98% in Sweden, respectively. However, differences in mortality at older ages were also large, as documented by survival curves from the age group 45-49 years (fig 1). If these life table estimates were applied to a cohort, only 36% of Russian men 45-49 years old would survive the next 25 years compared with 75% of Swedes; similarly, 34% of Russian men aged 70-74 years would survive another 10 years compared with 57% of similarly aged men in Sweden. The differences in survival between Russian and Swedish women were smaller but also clearly marked.

View larger version (29K): [in this window] [in a new window]   Fig 1 Proportion of people alive in each five year age group, relative to age group 45-49 years, in Russian and Swedish men and women (based on national life tables)

 

Until the age of about 55-59 years in men and 50-54 years in women, the prevalence of poor health is similar in the two populations (table). After those ages, the rates of poor health remain about stable in Sweden but increase rapidly with age in Russia. Physical functioning shows a similar picture (fig 2). The mean scores were similar until the age group 45-49 years in men and 35-39 years in women but thereafter the decline with age was much faster in Russia than in Sweden. In both sexes, the slopes of age related decline in health and functioning were significantly steeper in Russia than in Sweden (all P values < 0.001).

View this table: [in this window] [in a new window]   Age specific differences in self rated health and physical functioning between Russia and Sweden, with 95% confidence intervals

 

View larger version (39K): [in this window] [in a new window]   Fig 2 Mean score of physical functioning by age group in Russian and Swedish men and women

 

In the age group 45-49 years, 99% of Russian men and 97% of Swedish men and 89% of Russian women and 94% of Swedish women were free of disability. By combining the life tables with the survey data, we estimated the proportion of people both alive and without disability between the ages of 45-49 and 70-74 years in each country, relative to the 45-49 year age group (fig 3). The differences between Russia and Sweden were remarkable. Assuming again that these were data for a cohort, 65% of healthy 45-49 year old Swedish men would be alive and without disability 25 years later compared with only 17% of Russian men. The difference was similar among women: 65% in Sweden compared with 22% in Russia. The differences between the two countries were due to high rates of both death and disability in Russia, with death rate contributing more to differences in men and disability rate more to differences in women (fig 4).

View larger version (27K): [in this window] [in a new window]   Fig 3 Survival without disability between ages 45-49 and 70-74 years in Russian and Swedish men and women

 

View larger version (22K): [in this window] [in a new window]   Fig 4 Total survival and survival without disability to age 70-74 years among men and women without disability at age 45-49 years (proportions)

 

Discussion

In these cross sectional data, we found a much steeper age related decline in health and functioning in Russia than in Sweden, resulting in much worse health and functional status in elderly Russians compared with elderly Swedes. The combination of high mortality and high disability results in a huge difference in the estimated survival without disability in people from their late 40s to mid-70s between the two countries.

Though self rated health is a purely subjective measure, physical functioning score is based on 10 relatively specific questions and is less prone to reporting bias. The SF-36, the source of the questions on physical functioning, has been validated against clinical end points in many populations, including Russian. We also considered the possibility that the different methodology (interviews in Russia and postal survey in Sweden) could have led to differential reporting of disability. One would expect that such bias would affect all age groups. However, the levels of both self rated health and physical functioning were similar in the two populations in younger people and only started to diverge after the age of 40 or 50 years. At least for self rated health, the rates of poor health in this study are, if anything, higher than in a Swedish national interview study of people aged 55-74 years.⁹ In another survey comparing 50 year old men in Sweden and Lithuania, which used slightly different terminology, the differences in self rated health were even larger, with 7% of Swedes and 45% of Lithuanians reporting health as "not very good" or "not good at all."¹⁰ This argues against under-reporting of ill health in Sweden in our study. Moreover, as expected, the differences between the two countries varied by sex, being mainly due to mortality in men but disability in women. All this strongly suggests that the differences in health and physical functioning between the Russians and Swedes are genuine, rather than a methodological artefact.

One issue with survival without disability and healthy life expectancy is that they are based on data from people with a particular history that may not be applicable to other populations or cohorts. For example, the health status of 70 year old Russians may reflect wartime conditions—this may be particularly important given the increasingly recognised importance of life events.¹¹ Extrapolation to future cohorts may therefore be problematic, and the interpretation of our results needs to be cautious. We have focused on temporary differences between the two countries and have refrained from explicit predictions of future survival.

What is already known on this topic Russia has one of the lowest life expectancies in the industrialised world Most attention has been given to death rates of middle age men with little interest in the health of older people in Russia Disability levels in Russia have not been systematically studied What this study adds High levels of disability exist in elderly Russians The age related decline in health and physical functioning is much faster in older men and women in Russia than in Sweden In middle aged and older Russians survival without disability is about one third of that in Sweden

Our findings are consistent with results from the WHO healthy life expectancy project.^{12 13} On the basis of different data and methods, the healthy (that is, free of disability) life expectancy at age 60 years was 16.5 years in Swedish men and 8.5 years in Russian men; among women the figures were 18.5 and 12.7 years, respectively. These results show that the low life expectancy in Russia does not provide a full picture of the burden of ill health, as represented by the high rates of poor health and disability in this study and high rates of non-fatal cardiovascular disease reported by others.^{1 2} The alarming rates of disability in older men and women show that the health crisis in Russia is not confined to middle aged men. More generally, our data are consistent with recent evidence suggesting a decline of lifetime morbidity with increasing longevity.¹⁴ While this cross sectional comparison cannot replace longitudinal studies of the changes in mortality and health, the results support the view that extending length of life does not necessarily lead to high rates of disability at older ages.

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This is the abridged version of an article that was posted on bmj.com on 17 September 2004: http://bmj.com/cgi/doi/10.1136/bmj.38202.667130.55

We thank Michael Murphy for valuable comments on various drafts of the paper and the European Scientific Foundation scientific programme on social variations in health expectancy in Europe for useful discussions.

Contributors: See bmj.com

Funding: The Swedish study was funded by the County Council of Östergötland and performed by the LinQuest group at the Centre of Public Health Sciences in Linköping. The New Russia Barometer survey was maintained by the Centre for the Study of Public Policy (led by Richard Rose), University of Strathclyde, and funded by the Paul Lazarsfeld Society, Vienna, and the MacArthur Foundation. The analyses were supported by grants from the Wellcome Trust and by the MacArthur Foundation Initiative on Social Upheaval and Health. MM is the recipient of an MRC Research Professorship. The funders had no role in the design, conduct, analysis, or interpretation of the study.

Conflict of interest: None declared.

Ethical approval: The Swedish survey was approved by the ethical committee of the University of Linköping. The Russian survey was of non-medical nature and ethical approval was not required.

References

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(Accepted 26 July 2004)

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