Abstract
BackgroundCurrent measures to monitor population health include indicators of (i) average length-of-life (life expectancy), (ii) average length-of-life spent in good health (health expectancy), and (iii) variability in length-of-life (lifespan inequality). What is lacking is an indicator measuring the extent to which healthy lifespans are unequally distributed across individuals (the so-called ‘healthy lifespan inequality’ indicators).MethodsWe combine information on age-specific survival with the prevalence of functional limitation or disability in Spain (2014–2017) by sex and level of education to estimate age-at-disability onset distributions. Age-, sex- and education-specific prevalence rates of adult individuals’ daily activities limitations were based on the GALI index derived from Spanish National Health Surveys held in 2014 and 2017. We measured inequality using the Gini index.ResultsIn contemporary Spain, education differences in health expectancy are substantial and greatly exceed differences in life expectancy. The female advantage in life expectancy disappears when considering health expectancy indicators, both overall and across education groups. The highly educated exhibit lower levels of lifespan inequality, and lifespan inequality is systematically higher among men. Our new healthy lifespan inequality indicators suggest that the variability in the ages at which physical daily activity limitations start are substantially larger than the variability in the ages at which individuals die. Healthy lifespan inequality tends to decrease with increasing educational attainment, both for women and for men. The variability in ages at which physical limitations start is slightly higher for women than for men.ConclusionsThe suggested indicators uncover new layers of health inequality that are not traceable with currently existing approaches. Low-educated individuals tend to not only die earlier and spend a shorter portion of their lives in good health than their highly educated counterparts, but also face greater variation in the eventual time of death and in the age at which they cease enjoying good health—a multiple burden of inequality that should be taken into consideration when evaluating the performance of public health systems and in the elaboration of realistic working-life extension plans and the design of equitable pension reforms.
Highlights
IntroductionCurrent measures to monitor population health include indicators of (i) average length-of-life (life expectancy), (ii) average length-of-life spent in good health (health expectancy), and (iii) variability in length-of-life (lifespan inequality)
Current measures to monitor population health include indicators of (i) average length-of-life, (ii) average length-of-life spent in good health, and (iii) variability in length-of-life
As regards the healthy survival curves, we observe the expected pattern: they decline with age and they are more favorable for the higher educated groups. Both for women and for men, the declines of the healthy survival curves are more pronounced than their ‘survival-only’ counterparts. Such steeper decline suggests that the distributions of ages at physical limitation onset are more unequally distributed than the corresponding age-at-death distributions – an issue we will quantify
Summary
Current measures to monitor population health include indicators of (i) average length-of-life (life expectancy), (ii) average length-of-life spent in good health (health expectancy), and (iii) variability in length-of-life (lifespan inequality). The first one has promoted the creation of ‘health expectancy indicators’ (HE) that measure the number of years that individuals are expected to live in ‘good health’ under prevailing mortality and morbidity conditions. These measures combine the quantity and the quality (in terms of health) of the expected remaining years of life [1, 2]. The main proposal of this paper is to bring together these two strands of research into a coherent whole to obtain a deeper and more comprehensive understanding of contemporary population health dynamics To attain this goal, we introduce the concept of ‘healthy lifespan inequality’ (HLI), which is designed to investigate the extent to which healthy (and unhealthy) lifespans are unequally distributed across population members. Rather than looking at the distribution of complete lifespans, we suggest partitioning the latter in the periods that individual spend across health states and investigating how these periods are distributed across individuals
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