1. Measures of Population Health CONTEMPORARY METHODS OF MORTALITY ANALYSIS Lecture 5

2. Living longer but healthier? Keeping the sick and frail alive expansion of morbidity (Kramer, 1980). Delaying onset and progression compression of morbidity (Fries, 1980, 1989). Somewhere in between: more disability but less severe Dynamic equilibrium (Manton, 1982).

3. WHO model of health transition (1984)

4. Quality or quantity of life? Health expectancy partitions years of life at a particular age into years healthy and unhealthy adds information on quality is used to: monitor population health over time compare countries (EU Healthy Life Years) compare regions within countries compare different social groups within a population (education, social class)

5. What is the best measure? Health Expectancy Healthy LEDisability free LEDisease free LE (self rated health) DFLE DemFLE HLE Cog imp-free LE Active LE (ADL) Many measures of health = many health expectancies!

6. What is the best measure? Depends on the question Need a range of severity – dynamic equilibrium Performance versus self-report – cultural differences Cross-national comparability – translation issues

7. Estimation of health expectancy by Sullivan’s method

8. Life expectancy 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0102030405060708090100110 Age Survival probability Life expectancy

10. Calculation of health expectancy (Sullivan method) L x h = L x x π x Where π x - prevalence of healthy individuals at age x L x h - person-years of life in healthy state in age interval (x,x+1)

11. Probability to be in good or excellent health Andreyev et al., Bull.WHO, 2003

12. Probability to be in good or excellent health Andreyev et al., Bull.WHO, 2003

13. Choice of health expectancy indicators

14. Interview question: “How do you rate your present state of health in general?” Answer categories:  Very good  Good  Fair  Poor  Very poor Self-rated health } } Dichotomised

15. Interview question: “Do you suffer from any long-standing illness, long- standing after-effect of injury, any handicap, or other long-standing condition?” Long-standing illness

16. First question: “Within the past 2 weeks, has illness, injury or ailment made it difficult or impossible for you to carry out your usual activities?” Long-lasting restrictions (if “yes” to the following questions) Second question: “Have these difficulties/restrictions been of a more chronic nature? By chronic is meant that the difficulties/restrictions have lasted or are expected to last 6 months or more”

18. What is the best measure? Depends on the question Need a range of severity dynamic equilibrium Performance versus self-report cultural differences Cross-national comparability translation issues

19. Population surveys Provide more detailed information on specific topics compared to censuses Cover relatively small proportion of population (usually several thousand) Population-based survey – random sample of the total population; represents existing groups of population

20. New trends in health surveys Harmonization of surveys at world scale Biomarker collection

21. Large-scale study of health and retirement of older Americans Survey of more that 22000 Americans older than 55 years every 2 years. Started in 1992

22. HRS-harmonizing studies UK English Longitudinal Study of Ageing (ELSA) Study on Health, Ageing and Retirement in Europe (SHARE) WHO Study on global AGEing and adult health (SAGE) including Russia Отдельные исследования в Мексике, Китае, Индии, Японии, Корее, Ирландии

23. Is sex an “integral part” of health at older ages? What is health? Subjective measures Functional measures Biomeasures What aspects of health are most highly associated with sexual function at older ages? SEX HEALTH

24. National survey conducted in 1994/95 7,189 Americans aged 25-74 core national sample (N=3,485) city oversamples (N=957) Strata: age, self-reported health status Control variables : partner status, partner health, race, education

25. A 30-40 minute telephone survey A 114 page mail survey Number of respondents: 4,242 Number of respondents: 3,690

26. Domains of Inquiry Childhood family background Psychological turning Community involvement Neighborhood Life overall Social Networks Physical Health Sexuality Personal beliefs Work and Finances Children Marriage Religion

27. 80% 84% AGE 25-54 (n=1,436) AGE 65-74 (n=237) 37% 31% AGE 55-64 (n=414) 60% 56% Currently Sexually Active With Partner

28. IS SEX IMPORTANT? “How much thought and effort do you put into the sexual aspect of your life?”

29. CONTROL OVER SEXUAL ASPECT OF LIFE “How would you rate the amount of control you have over the sexual aspect of your life?”

30. Self-rated Health by age and sexual activity

32. Satisfaction with sexual aspect of life by age and self-rated health

33. 52.9% actively engaged in a sexual relationship, all with a male partner. Sexually inactive women report lower sex life satisfaction (2.30 vs 5.70, p<0.0001) Sexually active women more likely to report good physical health than sexually inactive women (57.3% vs. 42.7%, p<.05). MIDUS: Sexuality and Lifecourse Health Events

38. SEXUALITY AND HEALTH Self-rated physical health is higher among sexually active women Women with very good and excellent health are more sexually active at all ages Satisfaction with sexual aspect of life is higher among women with very good and excellent health compared to women with poor health

39. Bidirectional Relationship Biological / Physiological Mechanisms TIME Sexuality Health ?

40. How to Compare Sexual Activity Across Populations? We suggest to use a new measure – Sexually Active Life Expectancy (SALE) Calculated using the Sullivan method Based on self-reported prevalence of having sex over the last 6 months (MIDUS and NSHAP studies) Life tables for the U.S. population in 1995 and 2003 (from Human Mortality Database)

41. Prevalence of Sexual Activity by Age and Gender (MIDUS 1)

42. Prevalence of Sexual Activity by Age and Gender (MIDUS 1) Men and women having intimate partner

43. LE and SALE at Age 30 (MIDUS 1)

44. Sexually Active Life Expectancy at Age 30 (MIDUS 1)

45. Percent of Expected Life Without Sexual Activity at Age 30 (MIDUS 1)

46. Comparison with other surveys NSHAP - National Social Life, Health, and Aging Project, is an in-home survey of 3,000 persons aged 57 to 84 that collect biomarkers of health and physiological functioning to better characterize the health of survey participants. Rich source of data on sexuality at older ages. MIDUS-2 – second wave of the MIDUS study conducted in 2004- 2006

47. Introduction to:

48. http://www.icpsr.umich.edu/NACDA/ Public Dataset

49. NSHAP Collaborators Co-Investigators – Linda Waite, PI – Ed Laumann – Wendy Levinson – Martha McClintock – Stacy Tessler Lindau – Colm O’Muircheartaigh – Phil Schumm NORC Team – Stephen Smith and many others Collaborators – David Friedman – Thomas Hummel – Jeanne Jordan – Johan Lundstrom – Thomas McDade Ethics Consultant – John Lantos Outstanding Research Associates and Staff

50. Study Timeline Funding: NIH / October, 2003 Pretest: September – December, 2004 Wave I Field Period: June 2005 – March 2006 Wave I Analysis: Began October, 2006

51. Interview 3,005 community-residing adults ages 57-85 Population-based sample, minority over-sampling 75.5% weighted response rate 120-minute in-home interview – Questionnaire – Biomarker collection Leave-behind questionnaire NSHAP Design Overview

52. MenWomen (n=1455)(n=1550) AGE 57-6443.639.2 65-7435.034.8 75-8521.426.0 RACE/ETHNICITY White80.680.3 African-American9.210.7 Latino7.06.7 Other3.22.2 RELATIONSHIP STATUS Married77.955.5 Other intimate relationship7.45.5 No relationship14.739.0 SELF-RATED HEALTH Poor/Fair25.524.2 Good27.531.5 Very good/Excellent47.044.3 Est. Pop. Distributions (%)

53. Medical – Physical Health – Medications, vitamins, nutritional supplements – Mental Health – Caregiving – HIV Women’s Health – Ob/gyn history, care – Hysterectomy, oophorectomy – Vaginitis, STDs – Incontinence Demographics – Basic Background Information – Marriage – Employment and Finances – Religion Social – Networks – Social Support – Activities, Engagement – Intimate relationships, sexual partnerships – Physical Contact Domains of Inquiry

54. NSHAP Biomeasures Blood: hgb, HgbA1c, CRP, EBV Saliva: estradiol, testosterone, progesterone, DHEA, cotinine Vaginal Swabs: BV, yeast, HPV, cytology Anthropometrics: ht, wt, waist Physiological: BP, HR and regularity Sensory: olfaction, taste, vision, touch Physical: gait, balance

55. NSHAP Biomeasures Cooperation

56. Principles of Minimal Invasiveness Compelling rationale: high value to individual health, population health or scientific discovery In-home collection is feasible Cognitively simple Can be self-administered or implemented by single data collector during a single visit Affordable Low risk to participant and data collector Low physical and psychological burden Minimal interference with participant’s daily routine Logistically simple process for transport from home to laboratory Validity with acceptable reliability, precision and accuracy Lindau ST and McDade TW. 2006. Minimally-Invasive and Innovative Methods for Biomeasure Collection in Population-Based Research. National Academies and Committee on Population Workshop. Under Review.

57. Applying Biomeasures in NSHAP Uses of Biomeasures Population-Based Sample Clinic-Based Sample To detect and monitor risk for disease, pre-disease, disease, mortality OR to quantify and monitor function ++ To recruit or exclude people from study -++ To determine efficacy of intervention --++ To determine effectiveness of intervention +++ To identify biological correlates or mechanisms of social/environmental conditions ++-- ++ = Very well suited -- = Poorly suited

58. McClintock Laboratory (Cytology) Jordan Clinical Lab Magee Women’s Hospital (Bacterial, HPV Analysis) McDade Lab Northwestern (Blood Spot Analysis) Salimetrics (Saliva Analysis) “Laboratory Without Walls” UC Cytopathology (Cytology) NSHAP Biomeasures

59. Sex hormone assays Salivary Biomeasures Estradiol Progesterone DHEA Testosterone Cotinine

60. Salivary Sex Hormones (preliminary analysis) log(progesterone) Frequency log(estradiol) Frequency log(testosterone) Frequency Units: pg/ml

61. Nicotine metabolite Objective marker of tobacco exposure, including second-hand Non-invasive collection method (vs. serum cotinine) Salivary Cotinine

62. 10 ng15 ng34 ng 10% M 103 ng 30% M 344 ng M Nonsmoker Passive Occasional Regular 0.05.1.15.2 Fraction -50510 log(Cotinine) M = mean cotinine among female who report current smoking Bar on left corresponds to cotinine below level of detection Cut-points based on distribution among smokers Classification of Smoking Status by Cotinine Level in Females Distribution of Salivary Cotinine

63. C-Reactive Protein (CRP) Epstein-Barr Virus (EBV) Antibody Titers Dried Blood Spots Thanks, Thom and McDade Lab Staff!

64. Demographic Variables: – Age – Race/Ethnicity – Education – Insurance Status Self-Report Measures

65. Social/Sexuality Variables: – Spousal/other intimate partner status Cohabitation – Lifetime sex partners – Sex partners in last 12 months – Frequency of sex in last 12 months – Frequency of vaginal intercourse – Condom use Self-Report Measures

66. Health Measures: – Obstetric/Gynecologic history Number of pregnancies Duration since last menstrual period Hysterectomy – Physical health Overall health Co-morbidities – Health behaviors Tobacco use Pap smear, pelvic exam history – Cancer Self-Report Measures

67. Sexually Active Life Expectancy at Age 55

68. Percent of Expected Life Without Sexual Activity at Age 55

69. Sexually Active Life Expectancy at Age 55

70. Publication on sexuality Lindau, Gavrilova, British Medical Journal, 2010, 340, c810

71. Life expectancy and sexually active life expectancy (SALE) Based on the MIDUS study

72. Sexually active life expectancy and self-rated health Based on the MIDUS study

73. Conclusions Proportion of women having sex partner declines with age Amount of control over sexual aspect of life declines with age Self-rated physical health is higher among sexually active women Women have lower sexually active life expectancy compared to men