Current Trends Quality of Life as a New Public Health Measure -- Behavioral Risk Factor Surveillance System, 1993

A fundamental goal of the year 2000 national health objectives is to increase the span of healthy life for all persons in the United States (1). Public health programs, improved social conditions, and private medical care have contributed to the prolongation of life expectancy of U.S. residents at birth from 47 years in 1900 to 75 years in 1989. However, for some persons, increased life expectancy includes periods of diminished health and function (i.e., lowered health-related quality of life {HR-QOL}). Because population-based surveillance of good health has been limited, questions to assess HR-QOL were added to the 1993 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the preliminary findings about HR-QOL from the 1993 BRFSS and describes an index used to identify population subgroups with high and low HR-QOL.

The BRFSS is a continuous, state-based, random-digit-dialed telephone survey of the U.S. adult noninstitutionalized population. Data were analyzed from 44,978 persons aged greater than or equal to 18 years who resided in states in which 1993 data were available for analysis in early March 1994 (i.e., 21 of 49 participating states and the District of Columbia *). Although data were included for states from each region of the United States, southern border and Gulf states were underrepresented.

HR-QOL data were based on participants' responses to four questions: respondents were asked 1) "Would you say that in general your health is excellent, very good, good, fair, or poor?"; 2) "Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?"; 3) "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?"; and 4) "During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?" Response rates for these questions ranged from 98.3% to 99.8%. The questions assessed self-rated health (a previously validated item {2}), recent activity limitation, recent physical health, and recent mental health. The latter two items also were used to calculate a "good health days" (GHDs) index ** to estimate the number of days during the 30 days preceding the survey that respondents' overall health was good. GHDs are obtained by subtracting the sum of "not good" physical health days and "not good" mental health days from 30 days, with the restriction that the number of GHDs cannot be less than zero.

Overall, in the 21 states, substantial limitations were reported in 1993 for each of the four measures of HR-QOL. Fifteen percent of respondents reported "fair" or "poor" health; 32%, recent physical health limitations; 31%, recent mental health limitations; and 19%, recent activity limitations (Table_1).

Of the characteristics studied, the mean number of GHDs during the 30 days preceding the survey was highest for persons with annual household incomes of more than $50,000 (26.4 days), college graduates (26.2), and Asians/Pacific Islanders (26.2) (Table_2). The mean number of GHDs was lowest for persons who were aged greater than or equal to 75 years (23.0), who smoked 20 or more cigarettes per day (22.9), who were told by a health professional more than once they have high blood pressure (22.1), who were unemployed (22.0), who were separated from their spouses (22.0), who had less than a high school education (21.9), who had annual household incomes of less than $10,000 (21.1), who were told by a physician they have diabetes (19.9), and who were unable to work (10.7).

Mean numbers of GHDs varied substantially when respondents were grouped by annual household income, education, age group, and sex (Table_3). The mean number of GHDs was lowest (17.5 days) for men aged 35-49 years who had annual household incomes of less than $10,000 and a high school education or less (n=167). Each of the five groups with the lowest mean number of GHDs (less than 20 days) comprised persons aged 35-64 years who had an annual household income of less than $10,000 (combined n=362 men, 1140 women). The mean number of GHDs was highest (27.9 days) for men aged 50-64 years who had annual household incomes of more than $50,000 and at least some college education (n=646). Each of the five groups with the highest mean number of GHDs (27 or more days) comprised men aged greater than or equal to 35 years who had annual household incomes of more than $50,000 (combined n=2842).

Reported by the following BRFSS coordinators: P Owen, Alaska; J Senner, PhD, Arkansas; M Leff, MSPH, Colorado; F Breukelman, PhD, Delaware; C Mitchell, District of Columbia; E Pledger, MPA, Georgia; G Louis, MPA, Idaho; B Steiner, MS, Illinois; K Bramblett, Kentucky; R Lederman, MPH, Massachusetts; N Salem, Minnesota; P Smith, Montana; S Huffman, Nebraska; N Hann, MPH, Oklahoma; C Becker, MPH, Pennsylvania; M Lane, MPH, South Carolina; D Ridings, Tennessee; R Giles, Utah; P Brozicevic, Vermont; R Schaeffer, MSEd, Virginia; T Jennings, MPA, Washington; F King, West Virginia. Aging Studies Br, Div of Chronic Disease Control and Community Intervention, Behavioral Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The need to address and characterize HR-QOL has been reflected by the national year 2000 objectives and the National Institutes of Health (3). Health analysts have addressed key aspects of a definition of HR-QOL (which includes functional status and individual health perceptions) and approaches for distinguishing HR-QOL from overall quality of life (which includes HR-QOL and satisfaction with one's life and circumstances) (3-5). Because individual health perceptions reliably predict loss of function, morbidity, and mortality (2,6,7), health agencies are developing valid measures of such perceptions for use in surveys (8,9). Comprehensive, yet brief, measures, such as those described in this report, may be feasible for use in local surveys (10).

The BRFSS findings suggest that a GHDs index can identify differences in reported good health among population subgroups and in relation to other key factors (e.g., annual household income and education). For some groups, the calculation of fewer GHDs primarily was attributable to recent physical health limitations (e.g., among persons with diabetes), to recent mental health limitations (e.g., among cigarette smokers), or to both recent physical and mental health limitations (e.g., among persons unable to work) (Table_2). Refinement of this index in relation to other variables, including location and season, may further differentiate subgroups.

The findings in this report are subject to at least five limitations. First, the data were not weighted to reflect the complex survey design of the BRFSS. Second, less than half the states participating in the BRFSS were included in this analysis, and some geographic regions were underrepresented. Third, the GHDs group means were not adjusted for all potential confounders (e.g., annual income adjusted for household size) (Table_2 and Table_3). Fourth, differences by racial/ethnic groups may reflect cultural differences in how these measures are perceived (e.g., some groups may stoically deny health problems or be reluctant to report problems to strangers {2}). Finally, respondents were persons capable and willing to participate in the household telephone survey; therefore, some groups with lower levels of HR-QOL most likely were excluded.

Future analyses of the weighted 1993 BRFSS data from all 49 participating states will 1) refine and validate the GHDs index, 2) examine geographic and seasonal patterns of HR-QOL, and 3) assess the relation of these HR-QOL data to behavioral risk factors and to other HR-QOL data (e.g., National Health Interview Survey and other BRFSS data used to track "years of healthy life" for the year 2000 national health objectives). States can use their BRFSS data to identify population subgroups reporting low levels of HR-QOL that may require additional health services and to monitor temporal or secular changes in HR-QOL that may be associated with major social and health events (e.g., implementation of health-care reform).

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. Schechter S, ed. Proceedings of the 1993 NCHS Cognitive Aspects of Self-Reported Health Status Conference. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1994 (in press). (NCHS working paper; series no. 10).

3. National Institutes of Health. Quality of life assessment: practice, problems, and promise -- proceedings of a workshop. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1993.

4. Patrick DL, Bergner M. Measurement of health status in the 1990s. Annu Rev Public Health 1990;11:165-83.

5. CDC. Workshop on quality of life/health status surveillance for states and communities: meeting report. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1993.

6. Idler EE, Angel RJ. Self-rated health and mortality in the NHANES-I epidemiologic follow-up study. Am J Public Health 1990;80:446-52.

7. Segovia J, Bartlett RF, Edwards AC. The association between self-assessed health status and individual health practices. Can J Public Health 1989;80:32-7.

8. CDC. Consultation on functional status surveillance for states and communities: meeting report. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1993.

9. Hennessy CH, Moriarty DG, Zack MM, Scherr PA, Brackbill R. Measuring health-related quality of life for public health surveillance. Public Health Rep 1994 (in press).

10. Mosteller F. Implications of measures of quality of life for policy development. J Chronic Dis 1987;40:645-50.

* Alaska, Arkansas, Colorado, Delaware, District of Columbia, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Minnesota, Montana, Nebraska, Oklahoma, Pennsylvania, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia.

** Computation of this index assumed minimal overlap of reported "not good" health days (e.g., a respondent reporting five physical and three mental not good health days would have 30-(5+3)=22 GHDs). An alternative index that assumed maximal overlap (i.e., 30-5=25 GHDs for the same respondent) added only 0.4 mean days to the 24.8 overall mean days of the minimal overlap index.

TABLE 1. Responses * to health-related quality-of-life questions -- Behavioral Risk
Factor Surveillance System, 1993 +
==============================================================================================
                                                       Respondents & (n=44,978)
                                                       ------------------------
Question                                     Response        No.       (%)
-------------------------------------------------------------------------------
Self-rated health
                                             Excellent      10,764    (24.0)
                                             Very good      15,328    (34.2)
                                                  Good      12,162    (27.1)
                                                  Fair       4,654    (10.4)
                                                  Poor       1,961    ( 4.4)

Recent physical health
  (No. days when physical                       0 days      29,914    (67.6)
  health was not good during                  1-2 days       5,010    (11.3)
  the 30 days preceding the survey).          3-7 days       4,402    ( 9.9)
                                              >=8 days       4,919    (11.1)

Recent mental health
  (No. days when mental                         0 days      30,308    (68.5)
  health was not good during                  1-2 days       4,373    ( 9.9)
  the 30 days preceding the survey).          3-7 days       4,708    (10.6)
                                              >=8 days       4,833    (10.9)

Recent activity limitation
  (No. days when poor physical                  0 days      36,130    (81.1)
  or mental health kept you from doing        1-2 days       3,081    ( 6.9)
  your usual activities during the 30         3-7 days       2,472    ( 5.5)
  days preceding the survey).                 >=8 days       2,886    ( 6.5)
-------------------------------------------------------------------------------
* Responses to the last three questions were recorded in actual number of days but are sum-
  marized in this table in four response groupings.
+ Unweighted data from Alaska, Arkansas, Colorado, Delaware, District of Columbia, Georgia,
  Idaho, Illinois, Kentucky, Massachusetts, Minnesota, Montana, Nebraska, Oklahoma, Pennsyl-
  vania, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia.
& Numbers may not add to sample size because persons with missing values were excluded
  from this analysis.
==============================================================================================

TABLE 2. Mean number of "good health days" (GHDs) * and "not good" physical and mental health days during
the 30 days preceding the survey, by selected respondent characteristics -- Behavioral Risk Factor
Surveillance System, 1993 +
================================================================================================================
                                                                  Mean
                                                  --------------------------------
                                        No.               Not good      Not good
                                   respondents &          physical       mental
Characteristic                      (n=44,978)    GHDs   health days   health days
----------------------------------------------------------------------------------
Age group (yrs)
  18-24                                4,279      25.1       1.8           3.4
  25-44                               19,756      25.2       2.1           3.1
  45-64                               11,445      24.6       3.5           2.8
  65-74                                4,975      24.2       4.7           1.9
   >=75                                3,064      23.0       6.2           1.9

Sex
  Male                                18,383      25.7       2.6           2.2
  Female                              25,311      24.1       3.3           3.2

Race
  White                               37,836      24.8       3.0           2.8
  Black                                4,198      24.9       2.9           2.8
  Asian/Pacific Islander                 474      26.2       1.8           2.3
  American Indian/
   Alaska Native                         606      23.5       3.5           3.8

Hispanic origin
  Yes                                  1,207      24.2       3.1           3.4
  No                                  42,358      24.8       3.0           2.8

Educational level
  Less than high school graduate       6,333      21.9       6.0           3.6
  High school graduate                14,795      24.8       2.9           2.8
  Some college                        11,629      24.9       2.6           2.9
  College graduate                    10,858      26.2       1.9           2.2

Annual household income
         <$10,000                      5,569      21.1       6.3           4.4
  $10,000-$24,999                     12,630      24.3       3.2           3.0
  $25,000-$50,000                     13,243      25.8       2.0           2.5
         >$50,000                      7,404      26.4       1.7           2.1

Employment status
  Employed                            27,331      25.9       1.8           2.6
  Unemployed                           1,857      22.0       4.2           5.2
  Homemaker                            3,741      24.1       3.5           3.1
  Student                              1,578      24.6       2.2           3.5
  Retired                              8,042      23.8       5.1           1.9
  Unable to work                       1,099      10.7      16.3           8.9

Marital status
  Married                             24,218      25.3       2.7           2.4
  Divorced                             5,254      23.4       3.6           3.9
  Widowed                              4,618      23.1       5.4           2.5
  Separated                            1,194      22.0       3.7           5.4
  Never married                        7,582      25.3       2.1           3.0
  Unmarried couple                       757      24.5       2.3           3.6

Told by a physician they
  have diabetes
  Yes                                  2,074      19.9       8.1           4.0
  No                                  41,583      25.0       2.8           2.7

Told by a health professional
  they have high blood pressure
  Never told                          33,683      25.4       2.4           2.6
  Told once                            2,274      24.6       2.9           3.1
  Told more than once                  7,527      22.1       5.7           3.6

Cigarette smoking
  Never smoked                        22,505      25.5       2.6           2.3
  Former smoker                       10,904      24.6       3.5           2.5
  Smokes <20 cigarettes
    per day                            5,022      23.7       3.2           3.9
  Smokes >=20 cigarettes
    per day                            5,189      22.9       3.7           4.4

Health-care coverage
  Yes                                 38,290      24.9       3.0           2.6
  No                                   5,308      23.5       3.3           4.2

Total                                 43,694      24.8       3.0           2.8
----------------------------------------------------------------------------------
* GHDs are obtained by subtracting the sum of not good physical health days and not good mental health
  days from 30 days, with the restriction that the number of GHDs cannot be less than zero.  In this analysis,
  the sum of GHDs and not good health days for each population subgroup exceeds 30 days because some persons
  reported a total of more than 30 not good physical and mental health days.
+ Unweighted data from Alaska, Arkansas, Colorado, Delaware, District of Columbia, Georgia, Idaho, Illinois,
  Kentucky, Massachusetts, Minnesota, Montana, Nebraska, Oklahoma, Pennsylvania, South Carolina, Tennessee,
  Utah, Vermont, Virginia, Washington, and West Virginia.
& Numbers may not add to sample size because persons with missing values were excluded from this analysis.
================================================================================================================

TABLE 3. Mean number of "good health days" (GHDs) * during the 30 days preceding the survey, by selected demographic
characteristics -- Behavioral Risk Factor Surveillance System, 1993 +
======================================================================================================================
                                                                 Age group (yrs)
                                    -----------------------------------------------------------------------
                                       18-34          35-49         50-64            >=65           Total
Annual                              -----------    -----------    -----------    -----------    -----------
  household income   Education      Men   Women    Men   Women    Men   Women    Men   Women    Men   Women
-----------------------------------------------------------------------------------------------------------
       <$10,000    <= High school   23.2   22.5    17.5   18.9    17.9   17.9    20.7   21.5    20.3   20.8
                   Any college      25.1   22.3    20.7   19.6    22.0   20.4    20.7   23.1    23.4   21.7

$10,000-$24,000    <= High school   25.8   24.1    24.5   23.2    23.4   24.1    23.9   23.4    24.6   23.7
                   Any college      26.2   24.1    25.1   23.6    23.8   24.5    25.2   24.2    25.5   24.1

$25,000-$50,000    <= High school   26.3   24.2    26.3   25.0    25.8   25.0    26.3   26.2    26.2   24.8
                   Any college      26.9   25.0    26.7   25.1    26.3   25.7    26.3   26.0    26.7   25.2

       >$50,000    <= High school   26.2   25.1    27.2   25.4    27.1   25.8    25.7   25.4    26.8   25.4
                   Any college      26.6   25.7    27.4   25.6    27.9   26.0    27.0   26.3    27.3   25.7

Total                               26.1   24.3    26.1   24.2    25.2   23.9    24.3   23.3    25.7   24.0
-----------------------------------------------------------------------------------------------------------
* GHDs are obtained by subtracting the sum of "not good" physical health days and "not good" mental health days
  from 30  days, with the restriction that the number of GHDs cannot be less than zero.
+ n=44,978. Unweighted data from Alaska, Arkansas, Colorado, Delaware, District of Columbia, Georgia, Idaho,
  Illinois, Kentucky, Massachusetts, Minnesota, Montana, Nebraska, Oklahoma, Pennsylvania, South Carolina,
  Tennessee, Utah, Vermont, Virginia, Washington, and West Virginia.
======================================================================================================================

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