Towards a cross-cultural comparison on measuring disability in the elderly

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Content TOWARDS A CROSS-CULTURAL COMPARISON ON
MEASURING DISABILITY IN THE ELDERLY
by
Maria Cristina Corpus
A Thesis Presented to the
LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE IN GERONTOLOGY
December 1992
Copyright 1992 Maria Cristina Corpus
UMI Number: EP58991
All rights reserved
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a note will indicate the deletion.
Dissertation F\ibiisNfng
UMI EP58991
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
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UNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
University Park
Los Angeles, CA 90089
This thesis, written by { > 0 2 - 2 -
MARIA CRISTINA CORPUS
under the director of h er Thesis Committee, and approved by all its
members, has been presented to and accepted by the Dean of the Leonard
Davis School of Gerontology, in partial fulfillment of the requirements for
the degree of MASTER OF SCIENCE IN GFRONTOl n o v ___________________
Dean
Date S y / /û .
THESIS COMMITTEE
M Chairman
1 1
ACKNOWLEDGEMENTS
There were several individuals involved in this study. In particular, I
wish to acknowledge the contribution of the Chairperson of my Committee,
Eileen M. Crimmins, who provided the focus for this thesis and gave many
valuable suggestions to improve its content. Doing research under her direction
was a most rewarding experience. I am also indebted to Gerald A. Larue, a
member of the Committee, for his editorial comments and more importantly, for
his wit and humor which helped sustain me during difficult times.
Special thanks go to my parents for their moral support. The respondents
in the surveys used for this study also deserve special recognition. Through
them, I gained a better perspective of cultural issues that impact on health and
aging.
Finally, I salute my fellow students and friends at USC who, in the finest
Trojan tradition, came to my rescue at various points in the long process of
completing this research and gave generously of their time, their talents and
were always a great source of comfort.
Ill
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS............................................................................................ ü
LIST OF TABLES........................................................................................................... v
LIST OF FIGURES.................................................... vii
CHAPTER 1 INTRODUCTION................................................................................ .1
Statement of the Problem .............................. 2
Significance of the Study................................................................................................3
CHAPTER 2 REVIEW OF LITERATURE............................................................... 5
Origin and Definitions of Key Concepts.................................................................... 5
Recent Developments in Functional Status Measures................................................9 j
Relevant Literature........................................................................................................ 12 i
I
CHAPTER 3 DESIGN OF THE ST U D Y ................................................................ 20
Data Sources 20 |
Method..............................................................................................................................30
Operationalization of Concepts ..................................... 31
Subjects 31 ,
Limitations of the Study.............................................................................................. 34
CHAPTER 4 ANALYSIS OF THE DATA............................................................... 37
Comparison of Measures Used.....................................................................................37
Comparison of Activity Limitations............................................................................39
Comparison of Performance Based on Combined Measures
of ADL, Mobility and lADL in Two Selected Surveys....................................... 45
CHAPTER 5 FINDINGS OF THE STUDY.............................................................64
Discussion........................................................................... 64
Conclusions....................................................................................................................77
Recommendations .................................................. 79
IV
TABLE OF CONTENTS (continued)
Page
REFERENCES...............................................................................................................82
APPENDIX A ................................................................................................................ 86
APPENDIX B ......................... 88
V
CHAPTER 3
Table 1
Table 2
CHAPTER 4
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
LIST OF TABLES
Page ;
I
Salient Features of the Seven Surveys..............................................21
Demographic Characteristics
of Samples in Selected Studies.......................................................... 32
Percent of Sample with ADL
Limitations in Selected Studies.......................................................... 40
Percent of Sample with Mobility
Limitations in Selected Studies.......................................................... 42
Percent of Sample with LADL
Limitations in Selected Studies.......................................................... 43 ‘
Percent of Males and Females !
With Good Functional Ability
in Seven Countries.............................................................................. 47
Average Difference Per Year of
Age in Percent for Males and
Females (60-64 years to 85-89 years)
with Good Functional Ability i
in Seven Countries...............................................................................51
Average Difference in Percent
between Youngest (60-64 years)
and Oldest (85-89 years) Age Groups
for Males and Females with Good Functional
Ability in Seven Countries....................................................... .53
VI
LIST OF TABLES (continued)
CHAPTER 4
Page
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Percent of Males and Females Who
Can Do All the Activities
without Help in Four Countries . . .
.55
Average Difference Per Year of Age
in Percent for Males and Females
(60-64 years to 85-89 years) Who Can Do All
the Activities without Help in Four Countries.............................. 59
Average Difference in Percent
between Youngest (60-64 years)
and Oldest (804- years) Age Groups
for Males and Females Who Can Do All i
the Activities without Help in Four Countries...............................61
Comparison of the Wording Used
in Selected Studies to Measure |
Ability to Bathe (ADL) .................................................................... 66 |
Comparison of the Wording Used
in Selected Studies to Measure Mobility ............................67 i
i
Comparison of the Wording Used
in Selected Studies to Measure
Ability to Cook (lADL) .................................................................... 68
Comparison of the Instrument Design
in Each of the Selected S tu dies........................................................69
v i l
LIST OF FIGURES
Page I
I
CHAPTER 4
Figure la Percent of Males and Females
with Good Functional Ability
in Seven Countries............................................................................48
Figure lb Comparison of Functional Loss
from Youngest (60-64 Years) to
Oldest (85-89 Years) Age Groups
in Males and Females with Good
Functional Ability in Each of
the Seven Countries............................................................................49
Figure 2a Percent of Males and Females '
Who Can Do All the Activities |
without Help in Four Countries .......................................................56
Figure 2b Comparison of Functional Loss !
from Youngest (60-64 Years) to |
Oldest (804- Years) Age Groups |
in Males and Females Who Can ,
Do All the Activities without ■
Help in Each of the Four Countries..................................................57
CHAPTER 1
This chapter begins with an introductory statement. The subsequent
sections will present the research questions formulated for this study, as well as
the importance of this research and its contribution to the existing literature.
INTRODUCTION
Survival into old age, a phenomenon which gradually took place in
developed countries, has been seen to occur more rapidly in many parts of the
developing world (WHO, 1984). As populations age, a large proportion of the
very old are likely to experience many chronic and degenerative disorders which,
in turn, will limit their functional capacity (Barker, 1989; Manton et al., 1986).
For families who must provide care and institutions whose task is to plan and
develop supportive services, a primary concern is the elderly individual’s ability
to cope with daily living despite morbidity-related restrictions. In addition, the
need for more assistance becomes critical because of the frail elderly’s
decreasing levels of activity. To obtain estimates on the prevalence of disability
in older adults, indices of functional status have been developed. Now commonly
referred to as "activities of daüy living" (ADL) and "instrumental activities of
daily living" (lADL) these measures, and their many variants, have been used in
epidemiological studies of aging as well as in national and cross-national surveys
on the health status of the elderly (Andrews et al., 1986; Barker, 1989;
2
Heikkinen et al., 1983; Hing and Bloom, 1990; Leon and Lair, 1990; Shanas
1971; and Weiner et al., 1990).
STATEMENT OF THE PROBLEM
In recent years, some efforts have been directed towards comparing
research findings on the health and functional status of the elderly in different
parts of the world using indices of ADL and lADL. This study wiU attempt to
broaden the scope of these initial research by bringing together existing data
collected from national and cross-national studies of past decades. First,
however, it will examine the conduct of the assessment process to see how
measures of ADL and I ADL were used in different cultural contexts. Then, it
will determine whether similarities and/or differences exist across countries and
cultures.
The specific questions which this research paper will address are the
following:
1. Are the indices used to measure functional status in older adults
comparable across cultures?
2. Are the results on prevalence of disability reported in the different
surveys comparable to each other?
3. Is it possible to determine the level of functioning difficulty across
countries?
3
SIGNIFICANCE OF THE STUDY
Relatively little comparative cross-cultural research has been done on the
functional assessment of the elderly using measures of ADL and lADL. Perhaps
because population aging is a recent phenomenon, it is only since the 1970s that
a major effort has been made to focus on the health status and service needs of
the elderly in different countries. The World Health Organization (WHO)
initiated epidemiological studies in aging, both in Europe and in Asia, to assist
governments in these countries as they prepared to address the needs of a rapidly
growing elderly population. Individual national studies have followed.
However, substantial data on disability in the elderly are yet to be published
(Ikels, 1991). A paucity of comparative studies in the existing literature
remains. This paper draws attention to this lack of information. It shall
synthesize previous research results, thereby, adding a new dimension to the
assessment of physical functioning in the elderly. This cross-cultural perspective
on disability will further expand the limited information about functioning
difficulties among large populations of older adults in widely diverse societies.
SUMMARY
With populations aging rapidly, the proportion of elderly persons with
many and varied functional limitations due to chronic conditions has been rising
steadily. As a result, there has been a concerted effort in many parts of the
4
world, to study the health and functional status of older adults. Several research
projects have been initiated by the WHO, as well as, by individual countries to
obtain estimates of activity limitations reported by this special population. An
important goal in many of these surveys was to generate comparable data that
can be used for future studies.
This thesis wiU describe recent research on the study of disability.
Specifically, it will bring together data collected from selected surveys and
analyze them along with these three questions formulated at the beginning of this
study: (1) Are the indices used to measure functional status comparable?
(2) Are the results on prevalence of disability as reported in the different surveys
comparable? (3) Is it possible to determine the level of functioning difficulties in
a number of countries?
Little is known of comparative studies that deal with physical functioning
in old age. Research on this aspect of aging is just beginning. Results from this
study will further advance the existing knowledge base.
CHAPTER 2
This chapter will review the literature which traces the origins and
progress in the development of functional status measures. Highlights of this
section include a historical overview, a discussion of the conceptual
underpinnings of functional assessment, recent developments in measurement and
the focus on global aging. Pertinent issues-oriented literature including past and
present studies on disability in the elderly will also be reviewed.
ORIGIN AND DEFINHIONS OF KEY CONCEPTS
The earliest attempts to measure functional status in the elderly can be
traced to Ireland and Australia at the turn of the century. Largely as a result of
famines in these two countries, census surveys included items that yielded
estimates on the prevalence of sickness and its consequent restrictions on work
activity. Similarly, in Canada, Finland and the United States, health interview
surveys looked into chronic morbidity in large populations. Although
rudimentary in nature, these measures of "restricted activity" laid the foundations
for the development of contemporary concepts of disability in the measurement
of health status (Katz, 1983).
Gradually, the refinement of the indices began. Estimates on the
prevalence of morbidity included data on duration of illness and on severity of
6
illness. Thus in 1940, a hierarchical classification of disability, which included
information on severity of illness, was developed. A decade later, Canadian
health surveys used disability ratios (days of hospitalization for every 100 days of
disability) to determine service needs.
At about this time in the United States, a classification of basic activities
of daily living was formulated by the newly established Commission on Chronic
Illness. Several investigators presented categories describing a wide range of
functions, from locomotion and traveling to eating and hand activities; and
likewise, from muscle power to ability to communicate (Katz, 1983). These
measures were found to be impractical and unreliable because of vague
terminologies and differences in the types of activities listed.
From these initial efforts, more precise indices used to measure health and
functional status in the elderly followed. In the mid-1950s, Katz and his
colleagues introduced the ADL Scale which rates individuals on the presence of
six basic functions that include bathing, dressing, toileting, transfer, continence
and feeding (Katz, 1983). In childhood, these skills are acquired in this order:
eating (the simplest task) is first and bathing (the most complex) is last.
However, when a person is disabled, this specific sequence is lost. Persons lose
their ability to bathe first and eating last (Verbrugge, 1989; Fillenbaum, 1987).
Following recovery or rehabilitation, these functions are restored in a reverse
order. In testing this theoretical construct, Katz and his co-investigators observed
7
that patients recovering from hip fractures moved through three successive stages:
(1) return of independence in feeding and incontinence; (2) recovery in
transference and going to the toilet; and (3) recovery of independence in dressing
and bathing (Ernst and Ernst, 1984). The six ADL functions can be viewed as
hierarchically ordered and forming a Guttman scale (Rubenstein et al., 1984;
Kane and Kane, 1981). In a Guttman scale, the items are related in such a way
that a subject with a given attitude wiU agree with all the items on one side of
that position and disagree with the other items (Judd et al., 1991).
In 1969, Lawton and Brody introduced a model of human behavior which
would provide a frame of reference for functional assessment (Katz, 1983). They
theorized that human behavior can be viewed as varying in the degree of
complexity required to perform a variety of activities. At the lowest level is life-
maintenance. The more complex levels of functional health, perception-
cognition, physical self-maintenance, instrumental self-maintenance, effectance
(activity emanating from the motivation to explore) and social behaviors follow.
Based on the model, function is seen to exist in a hierarchy of domains, each
with its own set of tasks that can be ordered on a continuum, from simple to
complex (Katz, 1983).
Because previous attempts did not measure the whole range of "everyday
functional competence," Lawton and Brody (1969) developed the Physical Self-
Maintenance Scale (PSMS). An eight-point lADL Scale, the PSMS measures
8
competence in possible tasks performed by normal adults prior to old age. These
tasks which are requisite to living a minimally adequate social life include: use
of telephone, shopping, cooking, housekeeping, laundry, use of public
transportation, management of money and management of medication (Lawton,
1971). The inclusion of such activities as use of public transportation or
shopping reflect earlier thinking advanced by Freud, Havighurst and Kuhlen who
believed that locomotion and mobility are basic self-maintenance functions which
allow the organism to adapt to its environment (Katz, 1987). The PSMS, hke
Katz’ Scale, meets the Guttman scaling criteria.
While Katz and his colleagues facilitated the operationalization of
function, thus, demonstrating that function can be measured (Spitzer, 1987), it
was Lawton and Brody who provided the conceptual framework which the
domain of ADL previously lacked (Katz, 1983). As a result of this theoretic
milestone, three components of self-maintenance functions were identified: basic
ADL, mobility and lADL.
A strong association between ADL and lADL has been suggested in the
literature. Some investigators describe a hierarchical relationship. Others have
shown that both can be combined into a single hierarchical scale (Spector et al.,
1987).
9
Reviews on the validity and reliability of these scales are mixed. Katz
(1983) maintains that ADL and mobility items now have standardized definitions
and conditions of measurement so that a high degree of consistency has been
noted in clinical examinations, program evaluations, and health planning.
However, more empirical reliability analyses including further studies on observer
effects are recommended by others (Ernst and Ernst 1984). It must be noted that
the ADL Scale, as originally conceived, requires a skilled observer to rate the
patient’s performance based on personal observations made during the previous
week (Rubenstein et al., 1984). The PSMS, on the other hand, was designed to
be administered by any health professional using a variety of informants, i.e.
patient, family, institutional employees, friends or combinations. It has been
reported to have a high reproducibility coefficient of .96 (Lawton and Brody,
1969). Despite this, little information has been collected on the comparative
reliability or validity of data derived from different informants (Rubenstein et al.,
1984).
RECENT DEVELOPMENTS IN MEASURES OF FUNCTIONAL STATUS
Because neither health nor functional status are uni-dimensional concepts,
many investigators and practitioners began to devise more comprehensive
assessment techniques for measuring the functioning human being (Kane and
Kane, 1981). Recent developments in functional assessment have integrated
10
components of basic ADL, mobility and lADL into multi-dimensional measures.
Some of the more commonly used tools are the Older Americans Resource and
Service (OARS) Multidimensional Functional Assessment Questionnaire which
yields a summary rating of physical functioning, psychological functioning, ADL
functioning, social functioning and economic functioning (Kane and Kane, 1981);
Lawton’s Multilevel Assessment Instrument (MAI) which measures behavioral
competence in the domains of health, ADL, cognition, time use and social
interaction (Kane and Kane, 1981); and the Functional Life Scale (FLS) which
assesses five elements of performance in cognition, ADL, activities in the home,
outside activities and social interaction (Ernst and Ernst, 1984). Sections of the
OARS and the MAI were used in the Four-Country Study which will be
described later in this research paper.
In the field of global aging, the need to estabhsh criteria for measuring
health and functional status became necessary in view of the increase in numbers
of the elderly worldwide and of the rising proportion of older adults with chronic
conditions. Recognizing the far ranging implications of this phenomenon,
particularly in developing countries, the World Health Organization (WHO)
convened a Scientific Advisory Meeting in 1984 to study the epidemiology of
aging. This body recommended the use of the WHO-developed Classification of
Impairments, Disabilities and Handicaps as an alternative method to measuring
11
health, autonomy and disability. Based on the medical model of disease:
"Etiology > Pathology > Manifestation" (WHO, 1980), it became
necessary to expand this further to describe chronic progressive diseases and
their effects on the functional capacity of the individual (Manton et al, 1986),
thus:
"Disease > Impairment > Disability > Handicap"
where.
Impairment is "any loss or abnormality of psychological, physiological or
anatomical structure or function;" (WHO, 1980)
Disability is "any restriction or lack (resulting from an impairment) of
ability to perform an activity in the manner or in the range, considered normal;"
(WHO, 1980); and.
Handicap is a "disadvantage for a given individual, resulting from an
impairment or a disability that limits or prevents the fulfillment of a role that is
normal (having regard to age, sex, and social-cultural factors) for that individual"
(WHO, 1980).
These concepts have been field-tested by the WHO in a number of cross
national surveys (Manton et al., 1986; 1987). They have also been integrated
into an international classification system which emphasizes the assessment of
individuals on measures of ADL (WHO, 1984).
12
RELEVANT LITERATURE
As stated earlier, comparative studies on the functional assessment of the
elderly in various parts of the world have been very limited. Shanas (1971)
published what appears to be the first international comparative survey using
measures of "functional incapacity" of old people. By studying representative
samples of the elderly in five industrialized countries, i.e. the United States, Great
Britain, Denmark, Israel and Poland, the investigator measured their need for
community health services by obtaining an estimate of reported restrictions on
mobility. The results of the study revealed that 61 to 71 percent of persons aged
65-69 and 27 to 45 percent of persons aged 80 and over could perform all the
tasks assessed (Heikkinen et al., 1983). The selected list of six basic tasks were
as follows: (1) go out of doors (2) walk up/down stairs (3) get about the house
(4) wash/bathe (5) dress/put on shoes, and (6) cut own toenails. Interestingly
enough, the more complex indicators of mobility, as, use of public transportation
were not included in the survey questionnaire (Beall and Eckert, 1986).
A more recent use of ADL measures as an index of functionality is
described in a comparison of long-term care institutions in the United States and
in Sweden (Fries et al., 1991). Comparisons employed a resident classification
system, the RUG n, which links individual characteristics to resource use. Since
resource needs have been closely associated with functional capacity than
diagnoses, residents were assessed on three measures of ADL: toileting, eating
13
and bed/chair transfers. Results of the study showed that the distribution of the
ADL Index in Stockholm was different from that obtained in New York State.
The Stockholm data showed lower dependencies than those reported by the
residents in the New York State Skilled Nursing Facilities. However, when
compared with all the residents (Skilled Nursing Facilities and Intermediate Care
Facilities) it moved toward more intermediate levels of functioning. The
Stockholm average ADL index value of 5.79 was substantially lower than the
average ADL index value of skilled nursing facilities in New York State at 6.35
but close to the overall New York State average ADL index value of 5.66.
Both studies cited above reported a number of difficulties in conducting
cross-national surveys. Shanas (1971) points to differences in the interpretation
of the degree of the seriousness of diseases and the use of self-reported data as
probable sources for these variations. In the cross-national comparison of long
term care institutions, the researchers (Fries et al., 1991) have noted the
possibility of intrinsic bias in their research design because of the use of
different languages and data collection procedures. They conclude, however,
that several aspects of their findings suggest that if this had occurred, it does not
explain the described results. The data were collected from the entire nursing
home population in both study areas. This procedure, thus, eliminated the
difficulties that would have contrasted certain types of nursing homes found in
either country.
14
Ikels (1991) presents another perspective on the problematic aspects of
comparative studies. She questions the practice of administering research
instruments developed in the West to non-Westem samples. Drawing from her
many and varied experiences with the Chinese, she finds that back translations of
assessment tools sometimes contain unreliable items because "dictionary
equivalents" are substituted for "equivalent concepts." Back translations involve a
process where an instrument or a question is translated from one language into a
second language by one person and then translated back into the original
language by another person or a group of persons who have no prior knowledge
of the instrument or item. If the result is different from the original version, the
discrepancy is discussed and resolved by a team of experts (Palmore, 1983). The
importance of the problem of back translations was also highlighted by other
researchers. Despite the rigors of a well-designed process of back translation,
Andrews et al. (1986) found that the survey questionnaire they used in the Four
Country Study (one of the selected surveys for this research) had presented some
problems. They, therefore, caution that "transporting" assessment tools over
different cultures is perhaps the most serious defect of cross-national surveys.
Some solutions to the problem of back translations have been proposed.
Palmore (1983) suggests double-checking comparable measures to ensure
accuracy of translation and then pretesting them for reliability and validity in
each country. Others (Liang et al., 1987) recommend a critical evaluation of the
15
equivalence of survey instruments. To this end, they have identified three types
of equivalence: (1) conceptual equivalence which can be accomplished through
the back translation; (2) metric equivalence which implies that a given
measurement specification is applicable to different cultures; and (3) structural
equivalence where the causal linkages between a given construct and its causes
and consequences remain invariant across different cultures. The researchers
stress that these three criteria belong to a hierarchy where conceptual equivalence
precedes metric equivalence and that both are required for achieving structural
equivalence.
Further complicating problems in methodology is sample selection. For
example, age 65 is often regarded as the onset of old age in most Western
countries. Yet, Ikels (1991) has found that this may be too late for many of the
elderly in China. The groups she had studied presented pre-existing health
problems caused by long years of unsafe working environments. Therefore, to
accurately determine disability levels, it may be necessary to redefine old age in
different societies. CateU (1989) who discusses this point in greater detail writes
that one of the basic problems which repeatedly comes up in comparative
gerontology is the question: "What is ’old’?" and "Who are the ’old people, the
aged, the elderly’?" In a review of cross-cultural studies, she notes that many
social scientists, in their efforts to make their data comparable, use the
chronological standard set by the United Nations General Assembly at 60-65
16
years in selecting their population. However, in these research, nothing is said of
the subjects in developing countries who do not know their dates of birth and
therefore use estimates of their true ages. As a result, study populations are
sometimes classified on the basis of inaccurate information. Social-functional
indicators rather than the number of years lived may be the better method
although no one has yet been able to standardize cultural definitions of old age
(CateU, 1989).
Apart from methodological concerns, Ikels (1991) raises a conceptual
issue which involves the use of ADL and lADL measures in non-Westem
countries. She has observed that living alone, which is at the core of the indices
of functional status, is irrelevant in Hong Kong and in China. When young and
old people in Hong Kong were queried on whether they were able to live alone
and maintain their households, the answers elicited had almost nothing to do with
disability. Single households are rare in both countries. Many of the elderly
person’s personal care and household needs are carried out by younger members
of the famUy who live with them. A similar finding was reported in another study
by Ho (1991). To this day, the elderly in Hong Kong who Hve alone are to be
pitied while younger individuals who do the same become morally suspect.
National surveys also indicate that defects in methodology could distort
the interpretation of research findings. With data obtained from eleven surveys
measuring ADL in the United States in the 1980s, substantial differences were
17
noted on the estimates of American elderly with ADL disabilities (Weiner et al,,
1990). The investigators attribute the inconsistencies to: differences in which
ADLs were included (especially when counting the number of ADLs), how ADLs
were classified (i.e. by level of difficulty, type of assistance or duration of
problem), the age composition of the group surveyed, the sampling frame used,
the data collection procedures employed and chance sampling variability. Results
indicated that when essentially equivalent ADL measures were compared,
estimates for the community-based population varied by up to 3.1 percentage
points. For the institutionalized group, the variance (3.2 percentage points
toileting excluded) was about the same. While the differences in absolute terms
may appear small, the percentage differences across surveys were found to be
large. There were, for example, 60 percent more elderly Americans with
disabilities reported in the National Medical Expenditure Survey (NMES) than in
the Supplement of Aging Survey (SOA). Weiner at al. (1990) note, however, that
from a statistical perspective the estimates were fairly similar when they analyzed
the data on non-disabled elderly. Based on the figures reported, 95 percent of the
surveyed samples in the SOA and 92 percent of the subjects in the NMES could
do all the tasks assessed. Although ADL restrictions are generally low or rare
even among the elderly, the researchers claim that some variations in the
estimates of population size with reported disabilities are likely to occur.
18
There have been attempts, in recent years, to enlarge surveys of functional
assessments where the more complex instrumental activities of daily living are
included. These studies are the focus of this research paper and will be
discussed in the next chapter.
SUMMARY
Assessment of functional competence in older adults began with the use of
rudimentary measures of "restricted activity" or the inability to work as a result
of illness or a chronic condition. Then came a succession of other indices which
required continuous refinement. An important milestone in the measurement of
function occurred when Katz and his colleagues developed the ADL Scale. This
instrument rates individuals on six basic self-care functions. Lawton and Brody
later broadened the scope of everyday functional competence by including the
more complex instrumental activities of daily living. They constructed the
Physical Self-Maintenance Scale which contains eight possible tasks that normal
adults usually perform before the onset of old age. In recent years, ADL and
I ADL indices have been integrated into multi-dimensional assessment instruments
along with other measures of human functioning, i.e. psychological, social and
economic. Some of these instruments are described in this chapter. In the field
of global aging, the WHO developed a Classification of Impairments, Disabilities
and Handicaps as an alternative method to measuring health, autonomy and
19
disability in different cultures and societies. Setting this standard became
necessary in view of increased aging in many parts of the world.
In the literature, few cross-cultural studies on the measurement of health
and functional status in the elderly are reported. Investigators in the field have
raised methodological and conceptual issues concerning the conduct of these
research projects. To correct some of these defects, a number of solutions and
suggestions have been recommended.
20
CHAPTER 3
This chapter focuses on the research design of this study. It will describe
the data sources, methodology, operationalization of concepts and characteristics
of the study samples.
DATA SOURCES
The data presented in this paper have been collected from surveys
conducted over the past two decades to study health and disability in aging
populations. These research projects include two cross-national surveys, three
national surveys and two community surveys. They have been especially
selected for this study because they represent recent efforts toward measuring the
functional status of the elderly across cultures. As such, they provide an
excellent opportunity to: (1) examine state of the art definitions and measures
used in international studies and to establish if they have a common base; and
(2) determine whether there are differences or similarities in health and
functioning patterns between developed and developing countries. Further, data
generated from these surveys will indicate whether cross-cultural comparisons on
the physical functioning of the elderly are possible. Table 1 summarizes the
salient features of each survey. A brief description of the seven selected surveys
will follow.
21
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22
1. The Elderly in Eleven Countries: A Sociomedical Survey (Heikkinen et al.,
1983); Health, Lifestyles and Services for the Elderly (Waters, et al. 1989).
The goal of this interdisciplinary survey was to generate standardized and
comparable data from nationally representative samples on the health and
functional ability of elderly people and their use of health and social services
(Heikkinen et al., 1983). A key objective was to describe developmental trends
in health and disability from the youngest age group to the oldest age group of
elderly persons.
Ten member nations of the European Region of the WHO joined the
study: Belgium, West Berlin, Finland, France, Greece, Italy, Poland, Romania,
USSR and Yugoslavia. Kuwait, a member of the WHO in another region, also
participated.
Sixteen centers in the eleven countries were identified as study areas.
Except for rural Greece, the other participating countries were largely urban.
The survey population was selected through various sampling methods. They
were divided into six groups with five-year age ranges, i.e. 60-64 through 85-89.
Ideally, each center was to have 100 participants from each sex. This was not
always possible in the older age groups where fewer men could be found. In
sum, 16,671 males and females responded to the survey.
Analysis of the data focused on four aspects of health and functional
capacity: (1) present health status and past injuries, accidents, and chronic
diseases affecting basic tasks of daily living; (2) prevalence of various signs and
23
symptoms during the preceding two weeks; (3) prevalence of physical
impairments; and (4) capacity for self-care and functional status.
In the assessment of functionality, the instrument listed 14 items which
ranged from primary functions, as, eating to those requiring more performance
capacity, as, carrying heavy weights. The survey questionnaire was designed by
the Editorial Board for the Comparative Survey. Many items were adapted from
similar surveys although a number of new items were also added.
Following the publication of the "Eleven Country Study," the WHO-
commissioned researchers performed a more in-depth exploration of the variables
examined in this initial research. A second volume entitled Health, hfestvles and
services for the elderlv (Waters et al., 1989) was subsequently published. Unlike
the first report, which contained mostly descriptive data, this recent publication
offers more detailed analyses of health and functional ability, lifestyles and life
satisfaction, and primary care services for older adults. In measuring health and
physical functioning, the seven centers selected were: Belgrade, Berlin (West),
Florence, Rural Greece, Kiev, Kuwait and Tampere. These were chosen out of
16 study sites because: (1) of the greater similarity between these areas and (2) of
the almost uniform and standardized procedures observed in data-collection.
Results from this second analysis will be used in this paper. Approximately
8,500 men and women from ages 60-89 years participated in this study.
24
2. Aging in the Western-Pacific. A Four-Country Study (Andrews et al., 1986);
Morbidity and Disability Patterns in Four Developing Nations: Their
Implications for Social and Economic Integration of the Elderly (Manton et al.,
1987).
This study was sponsored by the WHO in response to the growth both in
absolute and proportional numbers of the elderly in the Western Pacific Region.
The future needs of the elderly in the domains of health and social care were a
primary concern of the researchers. Through this survey, they hoped to generate
data that would assist policymakers and service providers towards promoting the
well-being of this special population (Andrews et al., 1986).
Four countries participated in this study: Fiji, the Republic of Korea
(ROK), Malaysia and the Philippines. Except for Fiji (N=796), the survey
population included 800 or more older adults 60 years and over and who were
not living in institutions. Different sampling methods were used to define the
survey population. Study areas covered the entire country for Fiji and the ROK,
Peninsular Malaysia for Malaysia and the Tagalog Region for the Philippines.
The survey questionnaire collected information on demography, economic
resources, physical health and functional ability, mental health, health service use,
living conditions and way of life. To assess the health and physical functioning
of the survey population, five approaches were used: (1) self-evaluation of
health; (2) incidence of accidents, injuries or chronic illnesses; (3) prevalence of
signs, symptoms and health problems; (4) ability to perform indispensable daily
25
tasks; and, (5) inquiry into use of services. Twelve items from the OARS were
used to gather data on levels of functional difficulties.
In 1987, Manton and his co-workers reanalyzed the results from the Four
Country Study. Their objective was to test the association between chronic
morbidity and disability in developing countries - a relationship which has
already found empirical support in many developed nations. The researchers
drew up a list of ADL, mobility and lADL items following the guidelines
established in the WHO International Classification of Impairments, Disabilities
and Handicaps. By means of a multivariate procedure, the research examined
population subgroups constructed on the basis of probabilities of having certain
health and functional statuses (Kinsella, 1988). This information, along with the
data obtained from the primary survey (Andrews et al., 1986), will be analyzed
later in this research paper.
3. Analysis of a WHO-Sponsored Survey of the Disablement Process in
Indonesia (Manton et al., 1986).
The principal objective of the survey was to validate the disablement
process as described in the WHO Classification of Impairments, Disabilities and
Handicaps. Specifically, it sought to determine: (1) if there were patterns of
association between sociodemographic status and impairments, disabilities and
handicaps; and (2) if impairment patterns were different in the elderly group.
The survey was conducted in 14 out of 24 provinces in Indonesia. In each
26
province, both rural and urban areas were covered except for Jakarta which is
entirely urban.
The study population consisted of 2,180 persons who reported significant
physical and mental impairments, functional disabilities and handicaps in daily
living.
To identify this group, the survey questionnaire evaluated respondents for
chronic impairments (23 items), mental impairments (13 items), functional
disabilities (10 items), handicaps in daily living (4 items) and work, household or
social handicaps (18 items). Two analyses were done. The first looked at
disability at all ages and used the entire sample (N=2,180). The second analyzed
disability in the middle and old ages (N=876). This group consisted of
individuals 45 years and over.
4. Prevalence of Disability in Instrumental Activities of Daily Living Among
Elderly Japanese (Koyano et al., 1988).
This study was initiated to observe the prevalence of disability in
instrumental ADL and to determine the effects of age and sex on prevalence.
The sample consisted of 7,735 elderly (65-99 years of age) who were
residing in an urban district in Metropolitan Tokyo. Average age for both male
and female subjects was 73.5 years.
Assessment of prevalence of disability in instrumental ADL focused on
seven activities: (1) using public transportation (2) using the telephone (3) heating
water (4) shopping for daily necessities (5) preparing meals (6) paying bills and.
27
(7) managing deposits at a bank or a post office. These activities were taken
from a pool of 55 items which were pretested and intended for a mail survey.
Participants were asked whether or not they could perform each of the seven
activities. More than 75 percent of the total population completed the
questionnaire on their own while the rest were assisted by family members or
friends.
5. Health and Functional Status of the Elderly Population in a Polynesian
Population (Barker, 1989).
This case study looked at the number and types of impairments and
disabilities experienced by a representative sample of older adults 65 years and
over and living in Niue. Located in the Southwest Pacific, this island has
undergone the effects of population aging that has also been observed in other
developing countries.
Sixty three individuals, of whom 43 were females and 21 were males,
made up the sample population. These comprised 50 percent of the elderly
population found on the Pension List. At the time of the survey, the total elderly
population in Niue was 178.
Finding that many of the assessment tools developed in the West were not
suited to the needs of the Niuan elderly and the social setting in which they lived.
Barker (1989) constructed her own questionnaire. Certain features of the
instrument reflect the investigator’s understanding of Niuan culture. For
example, the elderly respondents were addressed in the third person.
28
Furthermore, questions (mobility excepted) were simply answered by a "yes" or
"no" unlike the use of multiple response options that are usually found in other
assessment questionnaires. The investigator adds, however, that the theoretical
underpinnings of physical functioning found in such instruments, as, Katz ADL
Scale, Lawton’s Instrumental Role Maintenance Scale and the Older Americans
Resource Service’s battery on health questions were integrated into the
instrument.
The study questionnaire looked at the following: (1) number and type of
acute and chronic health problems the subjects had experienced within the past
12 months and their use of health services, 9 items; and, (2) the impact of these
problems on the subjects’ way of life and functional abihty, 9 items.
6, Epidemiology of Aging in Hong Kong: Health Status of the Hong Kong
Chinese Elderly (Ho,1991).
In this research. Ho (1991) presents cross-sectional baseline data which
describes the health status of the population, 70 years and over. This report is
part of a longitudinal study to investigate the determinants of health in a Hong
Kong elderly cohort. The survey population included two groups: one totalled
709 and were living in the community; the other (N=321) were residents of
Homes for the Elderly. (Only data pertaining to the non-institutionalized group
will be considered for analysis in the next chapter). All of the subjects lived in
Shatin, New Town, Hong Kong. The researcher (Ho, 1991) notes that the sample
was not entirely representative of the Hong Kong elderly as a whole. However,
29
the sociodemographic characteristics of the community cohort were found to be
similar to those of the general elderly population in Hong Kong.
The interview protocol followed the model used in the WHO-Eleven
Country Study. Likewise in estimating levels of physical functioning, the
researcher used the same item pool developed for the WHO survey (Ho, 1991).
7. 1989 Survey of Health and Living Status of the Elderly in Taiwan:
Questionnaire and Survey Design (Taiwan Provincial Institute of Family
Planning, Population Studies Center and Institute of Gerontology, University of
Michigan, 1989).
Like most developing countries, Taiwan has been undergoing dramatic
shifts in its demography since the 1950s. This first large-scale comprehensive
survey on the elderly was conducted in 1989. The Taiwan government was
interested in examining the effects of the country’s social and economic progress
on family structures and the changing status of the elderly population.
The Taiwan survey had for its goal the development of an adequate
picture of the health, social and economic well-being of the elderly. It was
carried out for the following reasons: (1) to serve as a benchmark against which
to measure future changes in the health and hving status of the elderly; (2) as a
resource for a number of descriptive and analytic studies of the elderly; (3) as a
base for follow-up studies; and, (4) as a guide to policy and program formulation.
This survey included the entire elderly population in Taiwan 60 years and
over who were either living at home or were residents of "special households"
(i.e. nursing homes, old-age homes or long-term care hospitals).
30
A three-stage sampling was used to select the study population. Response
rate was outstanding at 91.8 percent. Persistent call-backs and a determined
effort to trace persons who had moved to other locations contributed to the
unusually high participation level.
The survey questionnaire contained eight separate sections. In the Health,
Health Care Utilization and Behavior section, there were 13 items all listed under
the category, "ADL." The findings that will be analyzed later in this paper were
obtained from an unpublished thesis which performed a secondary-data analysis
on the Taiwan Survey (Li, 1991). In this study, the researcher divided the Hst of
13 items into two groups, i.e. ADL (4 items) and lADL (9 items).
METHOD
Two sets of data wiU be analyzed. One will focus on the results of the
assessment on specific ADL, mobility and I ADL measures. Frequencies
indicating prevalence of disability on these tasks wiU be presented and a
descriptive analysis follows. The other data set shows the results of two cross
national surveys where subjects’ performance on combined indices of ADL,
mobility and lADL were given. Patterns in functional decline across countries by
sex will be described based on the averaged differences in percentage points
between youngest and oldest age groups and within age groups.
31
OPERATIONALIZATION OF CONCEPTS
Activities of Daily Living - refer to basic or primary functions essential for self-
care and include such tasks as eating, bathing, toileting and dressing.
Instrumental Activities of Daily Living - consist of household chores (i.e.
cooking, housework, child-minding) and social activities (i.e. telephoning,
traveling, attending religious ceremonies) which enable normal adults to fulfill
both personal and social roles.
Mobility - an ADL type of self-maintenance which includes getting out of the
house or walking long distances; for ease of comparison, mobility items will be
classified under a separate category in this paper - a distinction that has been
followed by some researchers (Ernst and Ernst, 1984).
Disability - any difficulty with basic physical movements, strengths or mobility
and is often associated with tasks of everyday life that a person cannot do alone
or can do alone but with difficulty (Verbrugge, 1989).
SUBJECTS
Table 2 provides some demographic characteristics of the study samples.
Data from six countries (Seven Countries, Four Countries, Niue, Shatin, Koganei
and Taiwan) show the breakdown by age, sex and marital status.
The samples consisted of non-institutionahzed elderly except in the Seven
Countries and in Taiwan where both institutionalized and non-institutionalized
32
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33
older adults were surveyed. The age composition of the subjects varied widely
from 60-89 years in the Seven Country Study, 60-80+ years in the Four Country
Study and Taiwan, 65-80+ years in Niue, 65-99 years in Koganei and 70-80+
years in Shatin.
All but two of the surveys (Shatin and Koganei) covered rural and urban
areas in both developing and developed countries.
Sample size also differed from 63 elderly in Niue to 8,500 elderly in the
Seven Country Study. Taiwan had the largest male population (57 percent male
to 43 percent female) followed by the Seven Countries (51 percent male to 49
percent female). The Four Countries had a slightly higher proportion of women
than men (51 percent female to 49 percent male). Interestingly, in Taiwan and
in the Four Countries where male-female ratios contrasted widely, both showed
more married than widowed or single elderly. In Niue and Shatin, women were
about twice the size of the male population and, as a consequence, the data
indicate more widowed than either married or single older adults. Similarly, in
Koganei, there were more women (56 percent) than men (44 percent). This
study, however, did not provide additional information on their marital status.
In terms of age groups, gradual decreases in sample size were observed
in most countries from age 60-64 years to age 75-79 years. At the oldest age
range (80+ years to 85-89 years), sharp drops in sample size were noted in all
the study areas except for Niue.
34
LIMITATIONS OF THE STUDY
Initially, the research design intended for this study involved a secondary
data analysis - a process where existing data previously collected for another
purpose undergoes reanalysis (Liang et al., 1989). However, this researcher was
unable to obtain access to the original data sets despite efforts to contact the
principal investigators. Given this limitation and with published research as the
only data source, this research paper will proceed with a descriptive rather than a
quantitative analysis of the findings collected from all the surveys.
Another limitation which must be emphasized involves the method of
sampling. As previously stated, of the seven selected surveys five included
samples of older adults living in urban and rural areas. In the process of
combining data from largely varied geographical sites, it was possible that
important information on rural and urban differences may have been lost. It
should be stressed, however, that these issues were discussed in each of the
selected studies.
The results obtained from the different surveys were not uniform. Only
two (Koganei and Taiwan) provided assessment data on aU the activities
indicated in their questionnaire, four gave estimates on some of the tasks that
were affected (Four Country Study, Indonesia, Shatin and Niue) while one (Seven
Country Study) did not report any assessment data on specific tasks.
35
Finally, a global assessment of functional competence was available in the
two largest surveys (Seven Country Study and Four Country Study). In these
research, overall performance on a range of tasks was derived by combining total
scores for all three categories used to measure functional ability, i.e. ADL,
mobility and lADL. Each, however, differed in the number of tasks assessed.
Because of these differences, a caveat with regard to the findings of this study is
necessary. The analysis, which this research will perform, is limited to only a
few tasks. The results, therefore, may obscure the true estimates of disability
levels across the sampled groups.
SUMMARY
Data to be analyzed in this study have been collected from seven surveys
conducted since the 1970s for the purpose of evaluating the health and functional
status of the elderly in several European countries, the Middle East and parts of
Asia. These studies include two cross-national surveys, three national surveys,
and two community surveys. Each differed in sampling selection, geographical
area, socioeconomic and cultural variables, assessment procedures and analysis of
the data. Against this background, this research paper will attempt to compare
prevalence of disability in different countries. The results reported will be
entirely descriptive. Differences in functional ability for gender and age groups
36
across countries will be described. Due to limitations of available data, caution is
recommended in the interpretation of the findings in this study.
37
CHAPTER 4
The comparison of assessment measures used in the different surveys
along with a comparison of activity limitations encountered by the sampled
groups will be presented in this chapter. Similarly, the data on the performance
of two samples of elderly on combined measures of daily activities will be
analyzed.
COMPARISON OF MEASURES USED
List of ADL
In contrast to the other surveys, the Four Countries included items on
bladder and bowel control, i.e. getting to toilet on time and wetting/soiling self.
However, there was general agreement on four basic ADL: bathing, dressing,
feeding and toileting except for Taiwan which had only the first item.
List of Activities on Mobility
Only two surveys (Seven Countries and Shatin) provided several
indicators for measuring mobility, i.e. move outdoors, walk between rooms, use
stairs, walk 30 minutes or carry 5 kilograms and walk 10 minutes. Walking was
listed in three surveys (Four Countries, Indonesia and Niue) while climbing stairs
was likewise found in three others (Seven Countries, Shatin and Taiwan).
Finally, all the surveys included an item on walking long distances.
List of lADL
The widest variation was seen in the lADL category. For example, both
Niuan and Indonesian studies had culture-specific items as child-minding (Niue)
and child-tending (Indonesia). All of these fell under a broader category of
"Handicaps Affecting Household Activities" in the Indonesian study. Attending
church services was stiU another lADL item listed as a social activity in Niue.
Similarly, the Indonesian study had its own series of familial and community
activities also found under "Handicaps." From their format, it appears that in
these two surveys their lists of ADL, mobility and I ADL were modeled after the
WHO International Classification of Impairments, Disabilities and Handicaps. In
the Koganei study, heating water was an item listed in addition to preparing
meals; and, managing deposits was a separate item from paying bills. The
Taiwan Survey included the following items under the category of lADL:
crouching, reaching up over one’s head, and using fingers to grasp or hold
objects.
Despite the differences, there were common lADL items found in several
surveys, i.e., cooking (Four Countries, Indonesia, Seven Countries, Niue and
Koganei); heavy housework (Seven Countries, Shatin, Indonesia and Taiwan);
shopping (Four Countries, Indonesia, Koganei and Taiwan); and traveling (Four
Countries, Koganei and Taiwan).
I
39 '
COMPARISON ON ACTIVITY LIMITATIONS
In comparing disability on specific activities reported by the different
sample groups, only those tasks which were so worded that they were identical
or almost identical across the surveys will be the focus of the analysis. In
addition since this is a comparative study, activity limitations reported in only
one survey have been excluded from the analysis.
Limitations on ADL
Table 3 shows the percentage of the sampled population with limitations
on ADL. Difficulties in bathing were most prevalent in all the regions: Four
Countries, 6.8 percent; Niue, 6 percent; Taiwan, 5.9 percent; and Shatin, 4.2
percent. Indonesia had no data.
For dressing, those who said they were restricted included samples from
these areas: Four Countries, 4.1 percent and Shatin, 3 percent. In Niue,
everyone could do the task unaided.
Difficulties in eating were highest in Indonesia, 3.3 percent; Four
Countries, 3.1 percent; and Shatin, 1.4 percent. By contrast, Niuan elderly had
no eating problems.
Some variations were seen in both grooming and toileting activities.
About 4.6 percent of the respondents in the Four Countries had problems with
grooming while Niuans reported no restrictions at aU. In toileting.
40
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41
limitations ranged from 3 percent in Shatin to a negligible 0.8 percent in
Indonesia while Niuan elderly reported no problems.
Limitations on Mobility
Data presented in Table 4 summarize the restrictions on mobility.
Inability to walk distances of 300-400 meters was reported by a third of the
population in Niue (33 percent), by less than a fourth of the respondents in the
Four Countries (23.6 percent), and by about a fifth of the elderly in Taiwan (19.2
percent). Least affected were the Indonesians (7 percent) and to some extent
those living in Shatin (16 percent).
Chmbing stairs was difficult for almost 26 percent of the elderly in
Taiwan and 17 percent for those living in Shatin.
Approximately 11 percent in the Four Countries and 8 percent in Niue had
walking problems. In striking contrast were the Indonesians where only 1.6
percent suffered impairments.
Limitations on lADL
Table 5 highlights the prevalence of disability on lADL. Ability to
perform domestic tasks was measured by three items: cooking, doing light
housework and engaging in heavy housework. Cooking problems were most
frequent among the Niuans, 29 percent and least frequent among the Indonesians,
0.9 percent. The study samples in the following areas were either unable to cook
or required some assistance to complete the task: Four Countries, 17.4 percent.
42
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Koganei, 15.9 percent and Shatin, 4 percent. Doing light housework, i.e. wash
dishes or sweep floors, was assessed in two surveys. Those who had difficulties
included subjects in Niue, 11 percent and Shatin, 9 percent. Engaging in heavy
housework, i.e. wash windows and floors or general house cleaning were items
asked of respondents in two surveys. Nearly 10 percent more of the elderly in
Shatin (49 percent) than those in Taiwan (39.1 percent) were limited in these
activities.
For shopping, there were substantial differences in two groups from 29.3
percent in the Four Countries to only 1.1 percent in Indonesia. Other groups who
said they had problems with shopping included: 10.8 percent in Koganei and
10.1 percent in Taiwan.
In using the telephone, a considerable number of persons in the Four
Countries or 39 percent had difficulties and to a lesser degree, the elderly in
Taiwan, 15.7 percent. Least restricted were the respondents in Koganei, 6.5
percent.
Managing one’s own money was most difficult for samples in the Four
Countries, 20.3 percent followed by the elderly in Koganei, 13.7 percent and
those in Taiwan, 8.1 percent.
Reporting limitations associated with traveling, i.e. driving one’s car or
using public transportation, were 33.7 percent from the Four Countries followed
by 19.8 percent in Taiwan and 14.2 percent in Koganei.
45
Lifting and/or carrying a heavy object and walking for a 100 meters were
included in two surveys. Activity restrictions were reported by almost equal
percentages of individuals in both Shatin, 33 percent and Taiwan, 32.5 percent.
COMPARISON OF PERFORMANCE BASED ON COMBINED MEASURES OF ADL,
MOBILITY AND lADL IN TWO SELECTED SURVEYS
Study samples in the two WHO-sponsored surveys were further evaluated
for their functional competence on a range of daily activities. In the Seven
Countries, a functional ability index was constructed which enabled the
researchers to classify respondents’ performance into three categories: good,
restricted or poor functional abilities. The functional ability index was derived
from scores obtained from the assessment of 13 tasks: move outdoors, walk
between rooms, use stairs, walk at least 400 metres, carry heavy things, use the
lavatory, wash and bathe oneself, dress and undress, get in and out of bed, do
own cooking, feed oneself, cut own toenails and do light housework. In the Four
Countries, a similar measure was used based on 10 tasks, i.e. eating, dressing and
undressing, caring for personal appearance, walking, getting in and out of bed,
taking a bath or shower, getting to the toilet on time, traveling beyond walking
distance, shopping, and handling one’s own money. Assessment data yielded two
groups: those who could do all the activities without help and those who could
not do all of the activities without help.
46
Since the number of tasks covered in the two studies are not the same,
the results from each of the surveys wül be described separately. Analysis will
focus only on the subjects who had good functional ability in the Seven
Countries and on those who could do all the daily activities without help in the
Four Countries. Differences in functional decline across age groups and sex will
be also be discussed.
Seven Country Study
Results indicate that functional ability decreased with age in both men
and women. Table 6, Figures la and lb show the percentage of men and
women with good functional ability. For men, the percentage of those who had
good functional ability declined from a mean of 61 percent (60-64 years) to a
mean of 19 percent (85-89 years). Increasing degrees of difficulty in carrying
out daily activities were reported in all the study sites although each had its own
characteristic slope. Tampere, by comparison, had the least gradient. Waters et
al. (1989) believe this may have been due to the exclusion of 20 percent males
(80-84 years) and 40 percent males (84+ years) who lived in institutions and
therefore the survey sample for Tampere was a relatively healthier group.
Functional deterioration in women followed the same pattern. There was
a decrease in the proportion of females who were functionally competent with
means ranging from 53 percent (60-64 years) to 8 percent (85-89 years).
47
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FIGURE la
PERCENT OF MALES IN SEVEN COUNTRIES
WITH GOOD FUNCTIONAL ABILITY
48
100
80 -
60 -
40 -
20 -
6 0 - 6 4 6 5 - 6 9 7 0 - 7 4 7 5 - 7 9 8 0 - 8 4 8 5 - 8 9
Age Group (Years)
PERCENT OF FEMALES IN SEVEN COUNTRIES
WITH GOOD FUNCTIONAL ABILITY
60 -
I
20 -
6 0 - 6 4 6 5 - 6 9 7 0 - 7 4 7 5 - 7 9 8 0 - 8 4 8 5 - 8 9
BELGRADE
WEST BERLIN
FLORENCE
RURAL GREECE
KIEV
KUWAIT
TAMPERE
-Q— BELGRADE
- • WEST BERLIN
-■ FLORENCE
-O RURAL GREECE
-■ KIEV
-O— KUWAIT
-A— TAMPERE
A ge G roup (Y ears)
Source: Waters et aL (1989). Health, lifestyles and services for the elderly.
49
68-98
Q ,
68-98
68-98
68-98
a.
6 9-99
6 8-98
t’8-08
69-99
68-98
a.
-98
-98
t’8-08
a.
-99
68-98
a.
69-99
50
The investigators (Waters, et aL, 1989) also point to large gender
differentials in two sites: West Berlin and Kiev. In West Berlin, there were 69
percent males and 46 percent females (60-64 years); and 20 percent males and 6
percent females (85-89 years) who could do all the tasks without difficulty. In
Kiev, the differences were as follows: 74 percent males compared to 48 percent
females (60-64 years); and 23 percent males (85-89 years) compared to 4 percent
females (85-89 years) with good functional ability.
By contrast, small differences between men and women were noted in
Belgrade, Florence and Kuwait. In Tampere, these small differences became
large at the two oldest age groups, 41 percent males against 6 percent females
(80-84 years) and 41 percent males against 11 females (85-89 years).
Differences between men and women on changes in functional ability
across age groups showed no consistent pattern. Table 7 lists the average
difference in decline for persons with good functional ability per year of age.
For example, there were large, as well as, small differences between males and
females in two countries at various age intervals: West Berlin (4.8 percent
males to 1.2 percent females at 72.5-77.5 years) and Rural Greece (4.6 percent
females to 1.2 percent males at 67.5-72.5 years); and. West Berlin (2.4 percent
males to 2.0 females at 82.5-87.5 years) and Rural Greece (1.4 females to 0.8
males at 62.5-72.5 years). In another instance, no differences in functional
decline were observed between men and women in two countries: Kuwait (1.8
51
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52
percent males to 1.8 percent females at 62.5-67.5 years) and Tampere (0.8
percent males to 0.8 percent females at 67.5-72.5 years). Similar variations in
male-female differentials were also found in the other study areas.
Functional declines across the 25-year age range were, likewise, varied.
Table 8 shows the average difference between the youngest (60-64 years) and
the oldest (85-89 years) age groups in percent of males and females with good
functional ability. A consistently low functional ability index in Rural Greece
indicated little change over time for its male population (1.04 percent).
However, Kuwait did not show a similar pattern although its subjects appeared
to be in poor health as those in Rural Greece. Tampere, which began with a
fairly high functional ability index, ranked next to Rural Greece indicating slight
declines (1.16 percent). For females, Kuwait and West Berlin which had the
lowest functional ability index at 60-64 years, had the least changes (1.24
percent for Kuwait; 1.60 percent for West Berlin).
By contrast, countries with a high functional ability index at the youngest
age group for both gender, i.e. Florence and Belgrade, showed more changes.
Functional loss in the male population in these countries were 2.36 percent
(Florence) and 2.08 percent (Belgrade); and, for their female population, 2.32
percent (Belgrade) and 2.0 percent (Florence). Overall, the average difference
in functional decline across countries between the youngest and oldest age
53
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54
groups was as follows: range for males, 1.04 percent to 2.36 percent and range
for females, 1.6 percent to 2.32 percent.
Four Country Study
As in the Seven Countries, the respondents in the Four Countries also
gave indications of diminishing functional ability with age. Table 9, Figures 2a
and 2b show the percentage of men and women who could do all the activities
without help. In males, the proportion of the sample who were independent in
daily activities decreased from a mean of 90 percent (60-64 years) to a mean of
60 percent (80+ years). In all the sites, increasing disability was moderate until
the oldest age groups (75-79 years and 80+ years) when substantial declines
became apparent, particularly, in Fiji (range 94 percent to 56 percent), Korea
(range 79 percent to 47 percent) and Malaysia (range 91 percent to 70 percent).
In the Philippines, only a slight decrease was observed in all the age groups
(range 96 percent to 87 percent).
Women showed a parallel decline. The percentage of those who could
do all the activities without any assistance decreased from a mean of 98 percent
(60-64 years) to a mean of 54 percent (80+ years).
Male and female differentials were small in all the sites. For example, in
Malaysia 98 percent females compared to 91 percent males at age 60-64 years
55
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FIGURE 2a
PERCENT OF MALES IN FOUR COUNTRIES
WHO CAN DO ALL THE ACTIVITIES WITHOUT HELP
56
100
90 -
80 -
I
70 -
60 -
50 -
7 5 - 7 9 804- 6 0 - 6 4 6 5 - 6 9 7 0 - 7 4
FUI
KOREA
MALAYSIA
PHILIPPINES
A g e G roup (Y ears)
PERCENT OF FEMALES IN FOUR COUNTRIES
WHO CAN DO ALL THE ACTIVITIES WITHOUT HELP
100
90 -
80-
g 7 0 -
60 -
50 -
FIJI
KOREA
MALAYSIA
PHILIPPINES
6 0 - 6 4 6 5 - 6 9 7 0 - 7 4 7 5 - 7 9
A ge G roup (Y ears)
804-
Source: Andrews et al. (1986). Aging in the Western Pacific: A four country study.
57
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58
had intact functioning. At age 80+ years, the figures were 64 percent females
compared to 70 percent males. It is to be noted that the difference, in this
instance, was reversed at the younger ages with women showing fewer
disabilities than men. In the Philippines, both males and females (60-64 years)
had fairly similar levels of intact ADL functioning, 96 percent males and 95
percent females. Large differences, however, were observed between men (87
percent) and women (58 percent) at the oldest age group (80+ years). For Fiji,
both men (94 percent) and women (94 percent) were functioning at parallel rates
at age 60-64 years. However, in the succeeding age groups (65 years through
80+ years), men were consistently better at functioning than women.
In comparing the differences in decline of physical functioning across age
groups by sex, a pattern emerged. Table 10 presents data on the average
difference in functional loss for persons who could do aU the activities without
help per year of age. The largest difference between men and women occurred
at the oldest age range for Korea (4.2 percent males to 0.6 females) and the
Philippines (7.6 percent females to 3.4 percent males). In Fiji, considerable
differences between men and women were found in two age groups: (2.6
percent females to 0.4 percent males at 67.5-72.5 years and 5.2 percent males to
3.0 percent females at 80+ years) while in Malaysia, differences were largest
prior to the oldest age range (1.6 percent males to 0 percent females at 72.5-77.5
years). The data further showed that gender differences increased from one age
59
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group to the next age group in Korea. This was not the case with Fiji, Malaysia
and the Philippines where the differences between men and women did not rise
consistently with advancing age. However, at the oldest age range substantial
male-female differences were found in all the four countries.
Finally, declines in functioning over a 20-year age range were mostly
varied. Table 11 indicates the average difference between the youngest (60-64
years) and the oldest (80+ years) age groups in percent of males and females
who could do all the activities without help. For men, the least change in
functioning ability was found in the Philippines (0.45 percent); it also had the
highest percentage of persons who could do all the tasks assessed at the
youngest age group. For women, only moderate levels of change were reported
in Malaysia (1.70 percent) where functional ability was highest at the start. In
contrast, Fiji which ranked next to Malaysia in percentage of women who could
function without help, had the most changes (2.30 percent). Korea, with its
consistently low functional ability for both gender, showed moderate change
when compared to the other male samples (1.60 percent); similarly, Korean
women presented little change when compared to their female cohort in the other
countries (1.65 percent).
In sum, the average difference for men and women in functional decline
over a period of 20 years was: range for men, 0.45 percent to 1.9 percent and
range for women, 1.65 percent to 2.3 percent.
61
Ç / 5
O
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C N
62
SUMMARY
Analysis of the data yielded three types of comparisons. The first one
dealt with a comparison of assessment instruments used to measure functional
status. This study found that lists of ADL, mobility and I ADL varied from
survey to survey. Differences were noted in the type and number of tasks, how
adequacy of performance was measured, the data-collection procedures followed
and the language used to administer the questionnaire. The second comparison
described the limitations reported by respondents on specific tasks of daily
living. Prevalence of disability was highest for bathing (ADL) and walking
(Mobility). For LADL, the variation of responses made it difficult to single out a
task that was most disabling for the largest number of respondents. The third
comparison focused on two large groups of elderly who were assessed on
combined measures of ADL, mobility and LADL. Different indices of functional
status were used in both surveys. The Seven Country Study listed 13 tasks
(Table 6) while the Four Country Study had 10 items (Table 7). In both, the
results show that functional loss increased with age for males and females.
Furthermore, women appeared to be in poorer health than men in the Seven
Countries while women seemed to be more functionally intact than men
particularly at the younger age groups in the Four Countries. At the two oldest
age ranges, however, substantial declines in women’s functional status were
63
observed in both study areas. Finally, important age and gender differences of
the two sampled populations were likewise noted.
64
CHAPTER 5
This final chapter will discuss the results of this study. It will include
recommendations for the measurement of functional status leading to more
comparable findings.
DISCUSSION
The purpose of this study was threefold: (1) to establish the
comparability of measures used to assess functional disability across different
countries; (2) to determine whether the results obtained from the different
surveys were comparable; and (3) to establish whether it was possible to
measure the level of functional disability in these countries.
The important findings that have emerged from this study are as follows:
On the Comparison of Measures Used
The list of tasks on ADL, mobility and lADL varied from survey to
survey. The questionnaire administered in the Seven Countries, Shatin and
Indonesia had the most number of tasks with 14 items each. In the Four
Countries and in Taiwan, the assessment tools had 12 and 13 items respectively
while that of Niue had nine items. The Koganei study questionnaire, which
focused on lADL only, contained seven items.
Other differences and/or similarities found in the measurement
instruments of the selected studies were the following: (1) the use of
65
questionnaires mostly back translations except for the Koganei and the Taiwan
studies; (2) data collection while apparently similar in method, i.e. personal or
proxy interviews, were far from being uniform because of differences in the ages
and background of the interviewers; and (3) the different ways of measuring
adequacy of performance in each of the surveys, i.e. some questionnaires asked
if respondents required human assistance or use of special equipment (Four
Countries and Niue for items on mobility) while others (Seven Countries, Shatin
and Taiwan) focused on the degree of difficulty and still another (Koganei)
asked if the subjects could simply do the listed task. Specific examples of how
the three categories of functioning ability were measured are shown in Tables
12-14; Table 15 illustrates the differences in the instrument design in each study
area. The survey questionnaires administered in both the Seven Countries and
the Four Countries are reproduced in the Appendices.
On the Comparison of Activity Limitations
Regional differences were small in three of the five listed ADL, i.e.
eating, dressing and bathing. However, some variations were observed in the
other two ADL, i.e. grooming and toileting. Of the five ADL, bathing appeared
to be the most problematic for aU the groups surveyed except for Indonesia
where no figures were given. This finding could have been due in part to
difficulties in gaining access to water and bathing facilities since a large
proportion of the sampled populations in all the study areas lived in the rural
66
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areas (Shatin excepted). Respondents from the Four Countries indicated that
these were problems in Fiji and in Korea. In Niue, Barker (1989) writes that
only a few Niuans have showers or baths in their dwellings. Taking a bath is
done in two ways, i.e. by squatting under a pipe connected to a common water
tank or by swimming in the sea. Most of the elderly with some functional
disability could do either activity only with help. Therefore, the nurses who
conducted the interviews found that although the individuals themselves made no
claims about difficulties with bathing, six percent needed to be reminded about
personal hygiene.
In the United States, the results of one study show a remarkable
similarity. Bathing was one of two most common ADL problems reported by
8.9 percent of elderly Americans who participated in the National Medical
Expenditure Survey (Leon and Lair, 1987).
Considerable mobility restrictions (i.e walking, walking long distances or
using stairs) were prevalent among the elderly in Taiwan and in Niue (using
stairs excepted). Barker (1989) states that questions about climbing stairs were
irrelevant in Niue since the typical dwelling places in the island were single
story high.
Walking for 300-400 meters was, by far, the most difficult for all the
groups surveyed. This was the only item where all the study areas provided
some assessment data. Cultural factors could be one plausible explanation. For
71
instance, Manton et al. (1986) daim that in many rural areas in Indonesia, the
ability to walk long distances is crucial while in developed countries a
corresponding ability might involve using different forms of transportation. Ho
(1990) in her study states that walking is a daily activity of the Hong Kong
Chinese elderly since many do not have access to privately-owned transportation.
Levels of disability on specific lADL varied across study populations.
From the data, it appears that the most disabled group were the elderly from the
Four Countries. They comprised the largest percentage of persons with
difficulties in about half of the listed lADL, i.e. shopping, managing own money,
telephoning, and traveling. No other group exceeded these number of
limitations. According to the researchers (Andrews et. al., 1986), respondents
had difficulties with shopping and traveling because most of them were unable
to walk without help particularly in the oldest age group. However, they
stressed that findings on lADL should be treated with caution. Going shopping
or handling money were tasks usually assigned to younger members of the
family in many Asian households. These items, they concluded, may not have
been accurate measures of independence.
Compared to the other samples, it would seem that Niuans found cooking
most difficult. The investigator (Barker, 1989) notes, however, that cooking is a
family group activity done over charcoal stoves or earthen pits. Therefore,
72
asking the elderly if they needed assistance with cooking was pointless because
everyone could get some help.
Difficulties in shopping and in cooking were infrequent among elderly
Indonesians. Perhaps, this is because it had the youngest sample population,
with ages ranging from 45 to 65+ years. This may also account for fewer
dependencies reported by the same group for walking (mobility) and for toileting
(ADL).
When compared to the samples from the Four Countries, Shatin and
Niue, the respondents from Koganei and Taiwan appeared to be better in lADL
functioning. For example, usage of telephone was least incapacitating in
Koganei and the values given were extremely low when compared to those
reported in the Four Countries. Part of the reason may lie in the unavailability
of telephones in the rural areas of the Four Countries while this may not be the
case in Koganei, a city located in metropolitan Tokyo. It must also be noted
that responses to telephoning and to preparing meals were dropped from the
analysis in the original survey of the Four Countries because the investigators
had difficulty interpreting the results across the different cultures (Andrews et
al., 1986). The figures presented for the Four Countries on ADL, mobility and
lADL (Tables 3-5) were derived from Manton et al. (1987) who reanalyzed the
original data set.
73
The variations on lADL limitations reported here have some similarities
with those observed among the elderly in the United States. For example, in a
study of three representative samples of elderly community residents, prevalence
of disability in doing heavy housework ranged from 35 percent to 45 percent
(Comoni et al., in Koyano et al., 1988). In this research paper, the findings on
limitations in doing the same task were 39.1 percent in Taiwan and 49 percent in
Shatin. In the most intensive study on disability in lADL to date, Fillenbaum (in
Koyano et. al., 1988) writes that the largest group of elderly needing help or
being totally disabled was noted in doing heavy housework, i.e. from 25 percent
to 35 percent while the lowest percentage was observed in using the telephone,
i.e. from 6 percent to 7 percent. Corresponding figures cited in this study were
as follows: 49 percent for doing heavy housework (Shatin) and 6.5 percent for
telephone usage (Koganei).
Finally, compared to the figures on mobility and lADL, the proportion of
the population with limitations on ADL was much lower. For example, in the
Four Countries, assessment data for each of the categories were as follows:
(1) ADL (range 6.8 percent to 3.1 percent); (2) Mobility (range 23.6 percent to
10.5 percent; and (3) lADL (39.7 percent to 17.4 percent). This pattern was
consistent in the other countries, i.e. Indonesia, Shatin, Niue and Taiwan.
Recent literature has demonstrated that in several population-based surveys on
74
the elderly, disability in ADL is low when compared to LADL limitations
(Koyano et al., 1988; Leon and Lair, 1990).
On the Comparison of Performance Based On Combined Measures of ADL,
Mobility and lADL in Two of the Selected Surveys
For the Seven Countries, the data indicate that functional ability
decreased with age in both men and women. Additionally, women seemed to be
more functionally impaired than men across all age groups. The researchers
speculate that this may represent the combined effect of surviving men being a
more select group and the relatively less physical and social activity performed
by their female cohort (Waters et al., 1989).
Changes in men’s and women’s functional abüity across the Seven
Countries over a 25-year age range presented some variations. For males, one
country (Rural Greece) which had a consistently low functional ability index
reported the least declines while another country (Tampere) which began with a
fairly high functional ability index also gave indications of minimal functional
loss. For females, two countries with low levels of functional ability (Kuwait
and West Berlin) showed little change over time. By contrast, in two other
countries (Florence and Belgrade), where both men and women had a high
functional ability index at the youngest age group, more changes in physical
functioning were observed.
75
Differences between male and female functional declines per age group
flowed into several directions. In most countries, the differences ranged from
large to small with increasing age. However, two countries (Kuwait and
Tampere) showed age groups where both men and women encountered similar
levels of functional loss.
In the Four Countries, male and female differences were often small with
women having fewer dependencies than men at the younger age groups. At the
oldest age range, substantial gender differences were noted in the Philippines and
in Fiji where women’s functional status was comparatively lower than that of
their male cohort. In Korea, by contrast, women seemed to function better than
men. Andrews et al. (1986) found that incontinence was common among
Korean men aged 80+ years. Based on their research, 38 percent in this age
group had difficulties with getting to the toilet on time. In the rural parts of
Korea, toilets are usually located outside most houses. Incontinence is
exacerbated during the winter season when many prefer the warmth of their beds
and remain indoors. This may partially explain why elderly women in Korea
appeared to be healthier than their male cohort at the oldest age group.
Differences in functional decline between men and women over a 20-year
cycle varied across countries. Contrary to the findings obtained from the Seven
Country Study, in the Four Countries a high level of functioning ability at the
start showed little change for the male sample in one country (Philippines) and
76
moderate change for the female sample in another country (Malaysia). Korea,
which had the lowest functional ability for both men and women, indicated
moderate change for its male sample and little change for its female sample.
Differences for each age group by sex showed a distinct pattern at the
two oldest age ranges where the largest differences between males and females
were found. Furthermore, in Korea the differences between men and women
increased with age. In Fiji, Malaysia and the Philippines differences between the
sexes were less consistent alternating from moderate to low from one age group
to the next age group. There were also instances, when no gender differences
were noted, that is, functional declines were similar for both men and women.
In general, the performance of the two sampled groups (Seven Countries
and Four Countries) using the combined measures of daüy activities shows an
increase in functional deterioration from the youngest to the oldest age groups
for both sexes. Moreover, these declines have been most dramatic at the end of
the spectrum.
Similar results have, likewise, been found in numerous national, state and
community surveys conducted in the United States where a consistent increase in
functional limitations was observed with advancing age (Comoni-Huntley et al.,
1985). Additionally, male-female differentials in functional ability per age group
in both the Seven Countries and the Four Countries seem to agree with findings
from European studies where, in most cases, the general level of women’s health
77
appeared to be poorer than that of men. However, data to the contrary have also
been reported (Heilddnen et al., 1986). In the United States, there is evidence
that older-aged women are relatively more disabled than men in carrying out
basic ADL (Shanas, 1980; Jette and Branch, 1981) while Feller (1983) found no
significant difference between men and women aged 75 years and over.
CONCLUSIONS
Firm conclusions on the comparability of measures used to assess
functioning difficulties across countries are not possible at this time because this
would have required pretesting specific items in the questionnaire to establish its
validity and reliability in the country where assessment would have taken place.
Based on reports from the selected surveys, this standard procedure was met
only in the Four Country Study. The variables used to measure everyday
activities were subjected to tests of reliability and validity. Reliability
coefficients were extremely high at .80 to 1.00. Item validity was obtained from
the evaluation of interviewers and the panel of experts assigned to the study.
Although there were no indications of a similar procedure in the other surveys,
the questionnaires used in Indonesia and Niue included many items that were
culture-specific thus enhancing their validity. Therefore, data on activity
restrictions reported by the sampled groups on five items for ADL, three items
for mobility and eight items for lADL were analyzed. Besides having identical
78
or almost identical wording, these tasks were similar in definitions and
terminologies thereby providing some bases for comparisons.
On the comparability of results reported in each study area, this issue is
likewise open to question because of basic differences in methodology, such as,
variations in study populations, data collection procedures and the method used
in the assessment of functional status. Furthermore, it must be stressed that the
economic structures found in each of the countries surveyed were not the same.
Most of the selected studies included both urban and rural areas.
Understandably, the living arrangements and lifestyles in these places were
considerably varied. One example which best illustrates a fundamental
distinction between rural and urban settings is found in the measurement of
mobility. In many instances, mobility required more physical exertion of the
elderly living in rural areas than of their cohort in the cities. As this research
paper has reported, walking long distances was a frequent daily activity among
many provincial elderly while public/private means of transportation were
options open to those found in metropolitan areas.
Culture, traditions and customs were also shown to have impacted on the
measurement of disability. In certain societies, some indices of lADL have
acquired a group orientation and were often done within familial contexts.
Therefore, these tasks were no longer valid measures of physical independence.
In other settings, however, the elderly were expected to do the same activities by
79
themselves or with some outside help. The expectations placed by different
cultures on what precisely an older adult can or cannot do thus becomes a key
issue. One can speculate that regional and international differences in functional
status may not only be due to age-associated deficits. Rather, the economic
development and sociocultural practices in many parts of the world though
unrelated to measures of physical functioning could provide one plausible
explanation for the observed variations in functional ability of the elderly in
different countries.
Finally, given the limitations of the data, it cannot be said unequivocally
that it was possible to measure physical functioning of the different groups of
elderly persons who participated in the seven surveys. The assessment data
obtained from the selected studies were limited to a few tasks, thus, making it
difficult to obtain a true estimate of the prevalence of disability in each of the
sampled groups. But Davies (1985), who has examined research on the
epidemiology of aging in many parts of the world, claims that such is the kind
of data that is currently available. Their foundations are quite limited. And, the
problems in methodology it wül involve in order to extrapolate from
uncontrolled data are considerable.
RECOMMENDATIONS
Definitions of ADL and lADL are numerous. In some, measures of
mobility are classified under ADL; in others, they are part of LADL. Moreover,
80
the tasks included in either ADL or lADL categories vary in type, number and
wording. In addition, the assessment of disability along these tasks differs in
several ways i.e., some evaluate the need for human assistance and/or the use of
special equipment; others measure the degree of difficulty while still others
simply ask whether the respondents are able to perform a specific task. These
differences introduce possible bias and make the interpretation of results
difficult. Therefore, methodologies need to be standardized. Definitions of key
concepts should be made clear. And, for international surveys, there should be a
consensus on how to measure physical functioning of elderly samples who come
from diverse cultures and settings.
The proliferation of instruments designed to assess functional status needs
to be reduced. Spitzer (1987), who has noted an epidemic of scales in the
domain of health measures, has argued for narrowing down the number to five
or three instruments which are already "on the shelf." He believes that a wide
array of tools seriously inhibits comparison of results, as well as, verifying the
significance of results across different studies which examine the same problems.
This observation could well apply to the measurement of disability.
In cross-cultural research, more comparable measures are essential. This
has long been an issue with many investigators in the field. Because problems
of health and functioning in the elderly are now being addressed by the
international research community, it is recommended that a more serious effort
81
be directed towards improving the psychometric properties of existing
instruments so that they obtain cross-cultural reliability and validity. With a
refined state of the art both in conceptualization and in measurement, only then
will the outcomes of cross-cultural surveys on health and aging gain wider
acceptance.
8 2
REFERENCES
Andrews, G.E. et al. (1986). Aging in the Western Pacific: A four country
study. Manila: WHO, Western Pacific Region.
Barker, J.C. (1989). "Health and functional status of the elderly in a
Polynesian population." Journal of Cross-Cultural Gerontology. 4:
163-194.
Beall, C.M. and Eckert, J.K. (1986). "Measuring functional status cross-
culturally." In C.L. Fry & J.Keith (Eds.), New methods for old-
age research (pp. 21-55). Massachusetts: Bergin and Garvey
Publishers, Inc.
Catell, M.G. (1989). "Being comparative: Methodological issues in cross-
cultural gerontology." Journal of Cross-Cultural Gerontology. 4
(1): 75-81.
Comoni-Huntley, J.C. et al. (1985). "Epidemiology of disability in the oldest
old: Méthodologie issues and preliminary findings." Milbank
Memorial Fund Quarterly/Health and Society. 63 (2): 350-357.
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Asset Metadata

Creator Corpus, Maria Cristina (author)

Core Title Towards a cross-cultural comparison on measuring disability in the elderly

Contributor Digitized by ProQuest (provenance)

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Format application/pdf (imt)

Language English

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-295732

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Legacy Identifier EP58991.pdf

Dmrecord 295732

Document Type Thesis

Format application/pdf (imt)

Rights Corpus, Maria Cristina

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

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University of Southern California Dissertations and Theses