Progress and Perspectives of Study on DETERMINANTS OF HEALTHY LONGEVITY IN CHINA A. Introduction of Chinese longitudinal survey; B. Correcting underestimation of disabled life expectancy in conventional MSLT method and application to healthy longevity study in China Zeng Yi Professor, Peking University and Duke University

A. A BRIEF INTRODUCTION to Chinese Longitudinal Survey on Healthy Longevity General Goals of the project To better understand determinants of healthy longevity, such as social, economical, behavioral, environmental and biological factors. To provide data information for academic research, health and aging policy analysis.

PROGRESS REPORT 1. Progress of longitudinal surveys in 1998, 2000, and 2002 (1) Achieved sample size distributions. -- Extensive questionnaire data were gathered from 8,959, 11,161, and 11,163 oldest-old aged 80+ in 1998, 2000, and 2002, respectively. -- Among them, 8,170, 10,457, and 12,656 interviews were conducted with centenarians, nonagenarians, and octogenarians, respectively; -- we interviewed 1,100 oldest-old siblings (117 centenarians, 308 nonagenarians, 675 octogenarians; some were interviewed more than once), constituting about 550 oldest-old sibling-pairs. -- Data on date/cause of death, health status, socioeconomic status, and degree/length of disability and suffering before dying, etc., were collected from 2,783, 2,406 and 1,449 deceased interviewees aged 100+, 90-99, and , respectively.

(2) Significant Extension of CLHLS study since Thanks to UNFPA, NIA, China Social Science Foundation, Peking University, Taiwan Province Academia Sinica and China Academy of Social Science, we added 4,894 younger elderly aged and 4,478 elderly interviewees ’ adult children aged into our sample in 2002 wave. -- The total sample size is now over 20,000 interviewees including oldest-old (focus), younger elderly (as a comparison group) and elders ’ adult children (intergenerational relations and healthy longevity).

Sample Distribution, Age Survival intervieweesdeceased (proxy interview) follow-upnewly interviewTotal MFTMFTMFTMFT 1998 baseline survey 80-89NA NA 90-99NA NA 100+NA NA TotalNA NA 2000 follow-up survey Total follow-up survey 35-65NA NA 65-79NA NA Total NA -- Not applicable

(3) Sampling areas -- The survey was conducted in the randomly selected half of the counties and cities of 22 provinces out of the total of 31 provinces where Han are majority. -- There were 631, 777, and 866 counties and cities in our 1998, 2000, and 2002 surveys, respectively. -- The population in the survey areas constitutes about 85 percent of the total population in China.

(4) Sample Design. -- We tried to interview all centenarians who voluntarily agreed to participate in the study in the sampled counties and cities of the 22 provinces. -- For each centenarian, one nearby octogenarian and one nearby nonagenarian of predefined age and sex were interviewed. “ Nearby ” – could be in the same village or on the same street, or in the same town or in the same sampled county or city. The predefined age and sex are randomly determined, based on the code numbers of the centenarians, to have more or less randomly selected comparable numbers of males and females at each age from 80 to Following the same sampling procedure as for those aged 80-99, we selected the sub- sample of the younger interviewees aged who lived near the centenarian interviewees, based on the codes of the centenarians. -- Follow-up interviewees who were still surviving and all centenarians in the sampled areas in the next wave. -- Those deceased interviewees were replaced by new interviewees of the same sex and age (or within the same 5-year age group).

-- Sub-sample of 4,478 elderly interviewees ’ adult children aged in 2002 in Gaungdong, Jiangsu, Fujian, Zhejiang, Shandong, Shanghai, Beijing, and Guangxi. -- If an elderly interviewee had only one eligible child (i.e., aged and living in the sampling areas), that child was interviewed. If an elderly interviewee had two eligible adult children, the elder or the younger child was interviewed if the elderly interviewee was born in the first 6-months or the second 6-months. If an elderly interviewee had three eligible adult children, the eldest, the middle, or the youngest child was interviewed if the elderly interviewee was born in the first 4-months, second 4-months or the third 4-months, and so on.

(5) Age reporting. -- Coale and Li (1991) concluded that the age reporting of Han Chinese elderly persons is reliable. As a pilot study of this research project, Wang, Zeng, Jeune, Vaupel (1998) reached similar conclusion. -- Coale and Li (1991) discovered that reported ages of the elders in Xinjiang, where minority ethnic groups are majority are seriously exaggerated. Thus, we did not include Xinjiang, Qinghai, Ningxia, Inner Mongolia, Tibet, Gansu, Yunnan, Guizhou, and Hainan, which have a high proportion of inhabitants belonging to ethnic minorities in our study. -- In the 22 selected Han-majority provinces, we CANNOT exclude minority groups, since excluding minorities in the same survey area would violate principles of equality among ethnic groups. -- Data analysis has shown that the overall age reporting in our CLHLS survey, which also included 7.3% minority interviewees, is acceptably good up to age 105. E.g., age distribution of centenarians interviewed in the 1998 baseline is similar to that of Swedish centenarians (see Figure 1 in Zeng and Vaupel et al., 2001).

Figure1. The age distribution of interviewed Chinese centenarians in 1998 and Swedish centenarians

-- However, we are very cautious about the small number of persons (about 150 in each wave) who reported an age of 106 or older. Using a numerical example, Wang, Zeng, Vaupel and Jeune (1998) illustrated why the suspicious age reporting at age 106 and above is not inconsistent with our conclusion that age reporting for Han Chinese oldest-old including centenarians aged appears to be of acceptable quality. My co-authors and I excluded super- centenarians aged 106 and above in all of our publications. -- How about the quality of the age-reporting of the 7.3% minority sub-sample in CLHLS? Researchers may suspect their age-reporting quality. -- If age exaggeration among the 7.3% minority sub-sample is more serious than Han, what would be the impact on the analysis using CLHLS?  The impact seems not significant, simply because the minority sub-sample size is 7.3% only.

Note: X-axis is the oldest old ’ s age in months. E.g., 960 months equal to 80 year-old (960=80*12), and so on.

(6) Data quality. -- Data quality evaluations, such as reliability coefficients and factor analysis, and the rates of logically inconsistent answers, have shown that the data quality of the 1998, 2000, and 2002 surveys is generally good, as compared to some U.S. and Canadian elderly surveys (e.g., see Table 3 and Appendix in Zeng and Vaupel et al., 2001).

-- However, we also realize that some problems exist in the data set. For example,  Chronic disease information were seriously under-reported.  We asked six Western-standard disposition-related questions in the 1998 baseline survey such as: “Some people stated that ‘I often feel lonely and isolated’; How similar are you to these people?” But a high proportion of the Chinese oldest-old were unable to answer these questions. Thanks to great help from Prof. Jacqui Smith and our Chinese colleagues, we revised these questions in 2000 and 2002 surveys. The index of personality measures reliability was substantially improved in 2000 (0.72) and 2002 (0.71) as compared to 1998 (0.63).  Compared to the census data, the CHLS death rates at ages 90 and over are fairly accurate, but the death rates at ages were somewhat underestimated (- 9.4% and -8.7% at ages & for males; -13.1% and –6.1% at ages & for females) – we need to pay serious attention to improve this in the next waves.

2. Data analysis to enhance healthy longevity research. Up to May 31, 2003, 63 published papers, 63 conference papers, and 8 graduate students theses, all based on CLHLS data. -- Much more further research is needed.

3. Academic workshops/conferences on CLHLS (1) “ Workshop on Chinese oldest-old: dialogues with policy makers ” Dec. 31, 1999, in Beijing; 20 participants. (2) “ First national conference on determinants of healthy longevity of the oldest-old in China ”, March 2-3, 2001 in Beijing. 105 participants. (3) A workshop presenting the major results of our 1998/2000 surveys and exchanges with leading researchers of HRS/AHEAD, Berlin Aging Study, NLTCS, LSADT, August 2001 at MPIDR in Germany. 30 participants. (4) “ International Symposium on Healthy Aging Studies in China ” (co-sponsored with IUSSP), Oct. 25, 2001, Beijing. 150 participants from 11 countries. (5) “ Second national conference on determinants of healthy longevity ”, May 12-13, 2004, Beijing. 150 Participants. (6) “ International workshop on data analysis of the Chinese Longitudinal Healthy Longevity Survey ” at MPIDR, Rostock, August 2-4, participants from 6 countries.

PERSPECTIVE 1. General plan of our 2005 and 2008 follow-up surveys (1) Survey areas: same as in 1998, 2000, and (2) Questionnaire and sample design: basically the same as those used in the 2002 survey, given the nature of the longitudinal survey; to improve whenever necessary.

Table 4. Expected sample distributions of the 2005 and 2008 follow-up surveys Note: a, those interviewees’ children who were aged 65 at the 2002 survey will be 68 and 71 in 2005 and 2008, respectively.

(3) Survey fieldwork, national and provincial training workshops: basically the same as in 2002 wave; to improve whenever necessary. (4) Informed consent, confidentiality, and voluntary participation will be carefully implemented in the survey. (5) Procedures of age validation will continue to be used; to improve whenever necessary. (6) Economics of aging. We plan to add about five questions that seek to delineate more detailed information concerning payments for health care, decision power over financial issues in the household, spouse ’ s paid job at the present time, and health insurance. (7) Dissemination. We will make our 2005 and 2008 follow-up survey micro data files (without individual identifiers) widely available to scholars in the fall of 2007 and 2010, respectively.

2. Data analysis to better understand the determinants of healthy longevity (1) Conventional demographic and statistical analysis. (2) Multi-wave longitudinal data analysis with greatly increased statistical power to evaluate trends of change in disability, healthy survival, mortality, and extent of suffering before dying. (3) International comparative analysis on trends in disability and healthy survival. (4) Analysis of the association of early life conditions with healthy longevity. (5) Explanatory factors of the extent of disability & suffering before dying. (6) Multi-level analysis. (7) Multivariate analysis on the impacts of cognitive functions and subjective well-being on healthy longevity. (8) Economic analysis of disability. (9) Impact of social activities (e.g. traveling, watching TV & public media, religious participation) on healthy longevity. (10) Multidimensional analysis on quality of life.

CORRECTING THE UNDERESTIMATION OF DISABLED LIFE EXPECTANCY: A New Method & Application to the Oldest Old In China Zeng Yi, Gu Danan, Kenneth C. Land

I. Introduction Previous research has indicated that the underestimation of disability is one of the major problems in research on population aging (Gill et al. 2002; Guralnik and Ferrucci 2002) We found that extant studies of active/disabled life expectancy based on multi- state life table implicitly assume that persons who die between ages x and x+1 (or ages x and x+n) do not change their functional status between age x and time of death.  Such unreasonable assumption has resulted in that the widely used disabled life expectancies based on conventional methods are significantly underestimated. Based on the unique CLHLS data on ADL before dying, we propose a new method to correct the underestimation of disabled life expectancy inherent in the MSLT method.

II. Methodology 1. Following formulas show that classical Multi-state Life Table method underestimate the disabled life expectancy: = =+ = ++ Bias in (2) （4）（4）

2. New method （ 1 ） Assuming a uniform distribution of both deaths and transitions between functional statuses between age x and x+1 or between age x and age at death, the new method which corrects the bias is: (3) （ 2 ） Proportion of deaths with morbidity status k before dying after age y among those with ADL status i at age y is: (6)

IV. Results and Discussion 1. Underestimation of disabled life expectancy by classic MSLT method ① Proportion of underestimated disabled life expectancy by conventional MSLT method at age 80 are 10% and 6% for males and females respectively. With advancing of age, such underestimation declines ----the underestimation of disabled life expectancy is statistical significant. ② The underestimation of disabled life expectancy is larger for males than for females. ③ The underestimation of disabled life expectancy is around 12% and 6% for males and females at age 65 respectively based on the extrapolation.

Gill et al. (2002) demonstrated that prevalence rates of disability at different waves with longer intervals between waves (e.g. 1-5 years) are substantially underestimated. Gill and colleagues proposed to substantially reduce the length of the observation intervals between interviews or using monthly telephone interviews ---- but largely increase the costs.

2. ADL status-specific mortality and transition rate by age and gender

3. Age and gender differentials in status-based ALE

4. Life table proportions of the extent of morbidity before dying among the oldest old who are active or disabled at initial ages The slight morbidity profile: refers to those who were ADL active & bedridden for <5 days (including not bedridden). The moderate morbidity profile: refers to those who were ADL active & bedridden for ≥5 days or ADL disabled & bedridden for <5 days. Severe morbidity profile: refers to those who were ADL disabled & bedridden for 5-59 days. The long-term severe morbidity profile: refers to those who were ADL disabled & bedridden for ≥60 days.

（ 1 ） ADL disability at Survey is strongly associated with the extent of morbidity before dying. （ 2 ） As compared to their male counterparts, Chinese oldest old women not only survive in a more likely disabled status, but also suffer more before dying （ 3 ） Our empirical results show that the life table proportions of slight morbidity death over initial age y generally do not decline with the increase of age y ----This is generally consistent with previous similar studies and provides additional evidence concerning debates on the hypothesis about compression of morbidity (Fries 1980), or Morbidity dynamic equilibrium (Manton 1982) reject the hypothesis of a pandemic of disability (Gruenberg 1977) ---- healthy longevity (i.e., achieving longevity while relatively compressing morbidity) is not impossible (Hubert et al. 2002)

V. Summary 1. This study demonstrates that estimates of disabled life expectancy based on conventional multi-state life table approach (which lack of ADL data before dying) are significantly underestimated. 2.This is the first time to provide age-sex-ADL status-specific mortality and transition rates and the estimates of ADL status- specific ALE for the oldest olds in a developing country. 3. This study has investigated the extent of morbidity before dying. 4. Further multivariate explanatory research are needed to overcome the limitations of this study.

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