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Health conditions and role limitation in three European
Regions: a public-health perspective
Gabriela Barbaglia, Núria Adroher, Gemma Vilagut, Ronny Bruffaerts,
Brentan Bunting, José Miguel Caldas de Almeida, Silvia Florescu, Giovanni
de Girolamo, Ron de Graaf, Josep Maria Haro, et al.
To cite this version:
Gabriela Barbaglia, Núria Adroher, Gemma Vilagut, Ronny Bruffaerts, Brentan Bunting, et al..
Health conditions and role limitation in three European Regions: a public-health perspective. Gaceta
Sanitaria, Elsevier España, 2017, 31 (1), pp.2-10. �10.1016/j.gaceta.2016.07.008�. �hal-02481709�
Original
article
Health
conditions
and
role
limitation
in
three
European
Regions:
a
public-health
perspective
Gabriela
Barbaglia
a,b,
Núria
D.
Adroher
c,
Gemma
Vilagut
b,d,e,
Ronny
Bruffaerts
f,
Brentan
Bunting
g,
José
Miguel
Caldas
de
Almeida
h,
Silvia
Florescu
i,
Giovanni
de
Girolamo
j,
Ron
de
Graaf
k,
Josep
Maria
Haro
l,m,
Hristo
Hinkov
n,
Vivianne
Kovess-Masfety
o,
Herbert
Matschinger
p,
Jordi
Alonso
b,d,e,∗aAgencyforHealthandQualityAssessmentofCatalonia(AQuAS),Barcelona,Spain
bUniversitatPompeuFabra,DepartmentofExperimentalSciencesandHealth,FacultyofPublicHealthandEducationinHealthSciences,Barcelona,Spain cUniversityofLucerne,FacultyofHumanitiesandSocialSciences,DepartmentofHealthScienceandHealthPolicy,Lucerne,Switzerland
dHealthServicesResearchUnit,IMIM-InstitutHospitaldelMard’InvestigacionsMèdiques,Barcelona,Spain eCIBERdeEpidemiologíaySaludPública(CIBERESP),Spain
fUniversitairPsychiatrischCentrum,KULeuven(UPC-KUL),Leuven,Belgium
gUniversityofUlster,SchoolofPsychology,ResearchInstituteofPsychology,NorthernIreland,UnitedKingdom hUniversidadeNovadeLisboa,FacultyofMedicalSciences,MentalHealthDepartment,LisbonPortugal iNationalSchoolofPublicHealth,ManagementandProfessionalDevelopment,Bucharest,Romania jCentroSanGiovannidiDioFatebenefratelli,Brescia,Italy
kNetherlandsInstituteofMentalHealthandAddiction,Utrecht,TheNetherlands
lParcSanitariSantJoandeDéu,FundacióSantJoandeDéu,SantBoideLlobregat(Barcelona),Espa˜na mCIBERenSaludMental(CIBERSAM),Spain
nNationalCenterforPublicHealthProtection,DepartmentofMentalHealth,Sofia,Bulgaria oUniversitéParisDescartes,DepartmentofEpidemiology,EvaluationandHealthpolicies,Paris,France pUniversityofLeizpig,DepartmentofSocialMedicine,OccupationalHealthandPublicHealth,Leipzig,Germany
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received24March2016 Accepted26July2016 Availableonline17October2016 Keywords:
Commonhealthconditions Rolelimitation
Disability
Populationattributablerisk
a
b
s
t
r
a
c
t
Objective:TodescribethedistributionofrolelimitationintheEuropeanpopulationaged18-64years andtoexaminethecontributionofhealthconditionstorolelimitationusingapublic-healthapproach. Methods:Representativesamplesoftheadultgeneralpopulation(n=13,666)aged18-64yearsfrom10 EuropeancountriesoftheWorldMentalHealth(WMH)SurveysInitiative,groupedintothreeregions: Central-Western,SouthernandCentral-Eastern.TheCompositeInternationalDiagnosticInterview(CIDI 3.0)wasusedtoassesssixmentaldisordersandstandardchecklistsforsevenphysicalconditions.Days withfullandwithpartialrolelimitationinthemonthprevioustotheinterviewwerereported (WMH-WHODAS).PopulationAttributableFraction(PAFs)offullandpartialrolelimitationwereestimated. Results:Healthconditionsexplainedalargeproportionoffullrolelimitation(PAF=62.6%)andsomewhat lessofpartialrolelimitation(46.6%).Chronicpainwasthesingleconditionthatconsistentlycontributed toexplainbothdisabilitymeasuresinallEuropeanRegions.Mentaldisorderswerethemostimportant contributorstofullandpartialrolelimitationinCentral-WesternandSouthernEurope.InCentral-Eastern Europe,wherementaldisorderswerelessprevalent,physicalconditions,especiallycardiovascular dis-eases,werethehighestcontributorstodisability.
Conclusion:ThecontributionofhealthconditionstorolelimitationinthethreeEuropeanregionsstudied ishigh.Mentaldisordersareassociatedwiththelargestimpactinmostoftheregions.Thereisaneedfor mainstreamingdisabilityinthepublichealthagendatoreducetherolelimitationassociatedwithhealth conditions.Thecross-regionaldifferencesfoundrequirefurtherinvestigation.
©2016SESPAS.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Enfermedades
comunes
y
discapacidad
en
tres
regiones
europeas:
una
perspectiva
de
salud
pública
Palabrasclave: Trastornosfísicos Trastornosmentales Discapacidad
Proporciónatribuiblederiesgo
r
e
s
u
m
e
n
Objetivo:Describirladistribucióndeladiscapacidadenpoblacióneuropeade18a64a ˜nosdeedady analizarlacontribucióndelostrastornosfísicosymentalesconunaperspectivadesaludpública. Métodos: Se analizaron muestras representativas de población general adulta (n=13.666) de 10paíseseuropeos participantesenlaIniciativaMundialdeEncuestasparalaSaludMental(World Mental HealthSurveys Initiative), agrupadosen tres regiones: Centro-Oeste,Sur y Centro-Este. La
∗ Correspondingauthor.
E-mailaddress:jalonso@imim.es(J.Alonso).
http://dx.doi.org/10.1016/j.gaceta.2016.07.008
0213-9111/©2016SESPAS.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
G.Barbagliaetal./GacSanit.2017;31(1):2–10 3 EntrevistaDiagnósticaInternacionalCompuesta(CIDI3.0)seutilizóparaevaluarseistrastornosmentales, ysietetrastornosfísicosfueronautorreportadosapartirdeunalistaestandarizada.Secontabilizaronlos díascondiscapacidadparcialytotaldelmesprevioalaentrevistautilizandounaversiónmodificadade laescalaWHO-DAS.Secalcularonlasfraccionesderiesgoatribuible(PAF).
Resultados: Lostrastornosmentalesyfísicosfueronimportantescontribuyentesaladiscapacidadtotal (PAF=62,6%)yenmenormedidaaladiscapacidadparcial(46,6%).Eldolorcrónicofueelúnicotrastorno quehacontribuidoaexplicartantoladiscapacidadtotalcomolaparcialenlastresregioneseuropeas.Los trastornosmentalessonlosquecontribuyenmásaladiscapacidadtotalyparcialenlospaísesdel Centro-OesteydelSur.EnlospaísesdelCentro-Este,dondelostrastornosmentalesfueronpocoprevalentes,la enfermedadcardiovascularfuelaprincipalcontribuyentealadiscapacidad.
Conclusión: Lacontribucióndelostrastornosfísicosymentalesaladiscapacidadenlastresregiones europeasestudiadasesimportante.Lostrastornosmentalesestánasociadosconunagrandiscapacidad enlamayoríadelasregiones.Esnecesarioincorporarelestudiodelimpactodelasenfermedadescomunes endiscapacidadalaagendadesaludpública.Senecesitanestudiosadicionalesqueprofundicenenlas diferenciasregionalesencontradas.
©2016SESPAS.PublicadoporElsevierEspa ˜na,S.L.U.Esteesunart´ıculoOpenAccessbajolalicenciaCC BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Disabilityhasbecomethemostimportantcomponentofthe burden of disease.1 In 2010, low backpain and major
depres-sivedisorderswererankedasthethirdandfourthleadingcauses ofdisabilityworldwide,afterHIV/AIDSandroadinjuries, accord-ing to disability adjusted life years (DALYs).1 Although DALYs
help to compare therelative magnitude of thedisease burden acrossdiseasesandcountries,theymightnotadequatelycapture the welfare impact of some diseases, for instance mental dis-orders,as theyhave a largeimpactonfunctioning and quality of life.2–4 According to theWorld Report on Disability,5
infec-tiousdiseases(e.g.,malaria,tuberculosisandsexuallytransmitted diseases);non-communicablediseases(e.g.,arthritis,hearing dis-orders,asthma) and injuries (roadtraffic injuries, occupational injuriesandviolence)areimportantcausesofhealth-related dis-abilityindevelopedcountries.
The World Mental Health (WMH) Surveys Initiative was launched by the World Health Organization (WHO) to collect comparabledataontheburdenofmental disordersaroundthe world.6TwoWHO-WMHreports3,4haveprovidedinformationon
theindividualand societal-levelimpactof thedisabilitydueto 19physicalandmentalconditionsinthegeneralpopulation.By meansoftheWHO-DisabilityAssessmentSchedule2.0,7 thefull
andthepartialinabilitytoperformdailyactivities,asmeasuresof functionalimpairment,wereassessed.Bothreportshave empha-sized,inagreementwiththeGlobalBurdenofDisease(GBD)2010 study1 thatbackandneckpain,amongphysicalconditions,and
depression,amongmentaldisorders,werethemostburdensome non-communicableconditionsworldwide.
In Europe, nearly 42 million persons of working-age from 15 Europeancountries(16.4%) reportedhavinga long-standing health problem or disability in 2002.8 However, good sources
ofdataondisabilityare notavailablein allEuropeancountries and cross-country comparisons are limited due to methodo-logical differences.9 While harmonization of data on disability
amongEuropeancountriesareunderwaybytheEuropeanHealth Interview Survey,2008(EHIS),there isstill limited comparable informationaboutthedisabilityburdenofhealthconditionsinthe working-agepopulationofEurope.
Heredatafrom10EuropeancountriesparticipatingintheWorld Mental Health surveys initiative (EU-WMH)10,11 were analysed
with two general objectives: first, to describe the distribution ofdisabilityinthepopulationaged18to64years;andsecond, to examine the contribution of health conditions to disability. We analysed thecontributionof mentaldisorders and physical conditionsontwoself-reportedmeasuresofdisability:complete
inability(i.e.,fullrolelimitation)andpartialability(i.e.,partialrole limitation)toperformdailyactivitiesinthreeEuropeanregions.
Materialsandmethods
Surveymethodandsamples
TenEuropeancountries(Belgium,Bulgaria France,Germany, Italy, theNetherlands, NorthernIreland, Portugal,Romania and Spain)participatedintheEuropeanWorldMentalHealthSurveys Initiative (EU-WMH). Household interview surveys were con-ducted between2001and2009onprobabilitysamplesof each country’spopulationaged18yearsorolderlivinginprivate house-holds. Institutionalized individuals as wellasthose not able to understandthelanguageofeachcountry,wereexcludedfromthe study.Computer-assistedpersonalinterviewing(CAPI)wereused exceptforBulgaria,werepaper-and-pencil(PAPI)formatwasused. Respondentswereselectedusingstratifiedmultistage clustered-areaprobabilitysamplingmethods(Table1).Responseburdenwas reducedbysplitting-upthesingleinterviewintoatwo-part pro-cessinallcountriesexceptforRomania(inwhichtheinterview wasadministeredinonepart).Part1wasadministeredtoall par-ticipantsand included thecorediagnostic assessment ofmood andanxietydisorders.Part2wasadministeredtoallrespondents withacertainnumberofmoodandanxietysymptomsandtoa randomproportion ofthosewho hadnone,and included ques-tionsaboutdisability,additionalmentaldisordersandinformation onphysicalconditions.Part2individuals wereweightedbythe inverseoftheirprobabilityofselection toadjust fordifferential sampling,andthereforeproviderepresentativedataonthetarget adultgeneralpopulation.Additionaldetailsaboutsampling meth-odsareavailableelsewhere.10TheEU-WMHtotalsamplesizewas
37,289,rangingfrom2,357(Romania)to5,473(Spain).Response ratesrangedfrom45.9%(France)to78.6%(Spain),withan over-allweightedresponserateof63.4%.Forthisparticularwork,the 13,666individualsaged18to64years,whocompletedPart2of theinterviewwereanalysed(Table1).
InstitutionalReviewBoards(IRB)ofeachcountryapprovedthis study.
Europeanregions
Countries weregrouped into three regions accordingto the UnitedNationsStatisticDivision:(i)Central-WesternEurope (Bel-gium, France,Germany,theNetherlands andNorthernIreland);
Table1
EU-WMHsurveys:samplecharacteristics,fielddates,andsamplessizesbycountrygroups.
Countrygroups Survey Samplingcharacteristicsa Fielddates Samplesize
(part1) Response ratec Samplesize (part2) Samplesize (part2)18-64 years Central-Western 15580 6882 5,493
Belgium ESEMeD Stratifiedmultistageclustered probabilitysampleofindividuals residinginhouseholdsfromthe nationalregisterofresidents.
2001-2 2419 50.6 1043 863
France ESEMeD Stratifiedmultistageclustered sampleofworkingtelephone numbers.
2001-2 2894 45.9 1436 1222
Germany ESEMeD Stratifiedmultistageclustered probabilitysamplefrom communityresidentregistries.
2002-3 3555 57.8 1323 1097
TheNetherlands ESEMeD Stratifiedmultistageclustered probabilitysampleofindividuals residinginhouseholds.
2002-3 2372 56.4 1094 1387
NorthernIreland(UK) NISHS Stratifiedmultistageclustered probabilitysampleofhousehold residents.
2004-7 4340 68.4 1986 924
Southern 14034 5960 4,780
Italy ESEMeD Stratifiedmultistageclustered probabilitysamplefrom municipalityresidentregistries.
2001-2 4712 71.3 1779 1466
Portugal NMHS Stratifiedmultistageclustered areaprobabilitysampleof householdresidents.
2008-9 3849 57.3 2060 1757
Spain ESEMeD Stratifiedmultistageclustered areaprobabilitysampleof householdresidents.
2001-2 5473 78.6 2121 1557
Central-Eastern 7675 4590 3,393
Bulgaria NSHS Stratifiedmultistageclustered areaprobabilitysampleof householdresidents.
2003-7 5318 72.0 2233 1682
Romania RMHS Stratifiedmultistageclustered areaprobabilitysampleof householdresidents.
2005-6 2357 70.9 2357b 1711
TotalEU-WMH 37289 63.4 17432 13,666
CAPI:computer-assistedpersonalinterviewing;ESEMeD:EuropeanStudyoftheEpidemiologyofMentalDisorders;NISHS:NorthernIrelandStudyofHealthandStress; NMHS:PortugalNationalMentalHealthSurvey;NSHS:BulgariaNationalSurveyofHealthandStress;PAPI:pencilandpaperinterviewing;RMHS:RomaniaMentalHealth Survey.
aMostWMHsurveysarebasedonstratifiedmultistageclusteredareaprobabilityhouseholdsamplesinwhichmoresubsequentstagesofgeographicsampling(e.g.,towns
withincounties,blockswithintowns,householdswithinblocks)toarriveatasampleofhouseholds,ineachofwhichalistingofhouseholdmemberswascreatedandoneor twopeoplewereselectedfromthislistingtobeinterviewed.Nosubstitutionwasallowedwhentheoriginallysampledhouseholdresidentcouldnotbeinterviewed.These householdsampleswereselectedfromCensusareadatainallcountriesotherthanFrance(wheretelephonedirectorieswereusedtoselecthouseholds)andtheNetherlands (wherepostalregistrieswereusedtoselecthouseholds).SeveralWMHsurveys(Belgium,Germany,Italy)usedmunicipalresidentregistriestoselectrespondentswithout listinghouseholds.
b RomaniadidnothaveanagerestrictedPartIIsample.
c Theresponserateiscalculatedastheratioofthenumberofhouseholdsinwhichaninterviewwascompletedtothenumberofhouseholdsoriginallysampled,excluding
fromthedenominatorhouseholdsknownnottobeeligibleeitherbecauseofbeingvacantatthetimeofinitialcontactorbecausetheresidentswereunabletospeakthe designatedlanguagesofthesurvey.
(ii)SouthernEurope(Italy,PortugalandSpain);and(iii) Central-EasternEurope(BulgariaandRomania).
Measurements 1)Mentaldisorders
DSM-IVmentaldisorderswereassessedusingtheWHO Com-positeInternationalDiagnosticInterview(CIDI),12version3.0,
a fully structuredresearchdiagnosticinterview designed for usebytrainedlayinterviewerstoprovidediagnosesof men-tal disorders according tothe definitions and criteria of the DiagnosticandStatisticalManualofMentalDisorders(DSM-IV). Standardizedcommonprocedureswerefollowedtoguarantee cross-surveycomparabilityofdata.13Mentaldisorders
evalu-atedwere:Depressivedisorder(majordepressiveepisode),and anyanxietydisorder(panicdisorderand/oragoraphobia,social phobia,specificphobia,generalizedanxietydisorderand post-traumaticstressdisorder).
2)Physicalconditions
Physical conditions were assessed with a checklist based ontheU.S. NationalHealthInterview Survey.14 Respondents
wereaskedaboutanumberofsymptom-basedconditionsand anumber ofsilentconditions,diagnosed bya health profes-sional.Sevenconditionsorgroupsofconditionswereincluded: arthritis, cardiovascular disorders (heart attack, heart dis-ease,hypertensionandstroke),severeheadachesormigraines, insomnia, chronic pain (back or neck pain or other chronic pain),respiratorydisorders(seasonalallergies,asthma,chronic obstructivepulmonarydisease,emphysema),andotherphysical conditionswithlowprevalenceestimates(<2%),whichincluded cancer,neurologicaldiseases, diabetes,ordigestivedisorders (stomachorintestineulcerorirritableboweldisorder).
Both mental disorders and physical conditions had to be presentinthe12-monthsbeforetheinterview.
3)Disability
Role limitation was assessed with a modified version of theWHODisabilityAssessmentSchedule2(WMH-WHODAS),7
G.Barbagliaetal./GacSanit.2017;31(1):2–10 5
basedontheconceptualmodeloftheInternationalClassification ofFunctioning,DisabilityandHealth(ICF).Respondentswere askedaboutthenumberofdaysinthelast30days,inwhichthey weretotallyunabletocarryouttheirdailylifeactivities(fullrole limitation)ortheywereabletoperformtheirdailylife activi-ties,butonlypartially(partialrolelimitation).Adaywithpartial rolelimitationwasdefinedasadayonwhichrespondentshad either(a)tocutdownonwhattheydid,(b)tocutbackon qual-ityofwhattheydid,and(c)neededextremeefforttoperform asusual.Anaggregatemeasureofpartialrolelimitationwas computed:([0.50]*quantitycutdowndays)+([0.50]*qualitycut backdays)+([0.25]*extremeeffortdays).Ifthissumexceeded 30, it was set to 30 giving the measure a range from 0 to30.3,4
Statisticalanalysis
Weusedatwo-partmodellingapproachtoseparatelyassessthe associationoffullandpartialrolelimitationwithhealthconditions, controllingforage,sex,employmentstatus,education,marital sta-tusandcountry.Interactionswithsexweretestedinallmodelsbut interactiontermsdidnotreachstatisticalsignificanceinanymodel. First,alogisticregressionequationwasusedtopredictthe prob-abilityofreportingdayswithrolelimitationsinthetotalsample. SubsequentlyaGeneralizedLinearRegressionModelequationwas usedtopredictthescoresinthoseindividualsreportingdayswith fullandwithpartialrolelimitation(thespecificationforboth out-comeswasanormaldistributionwithanidentitylinkfunction).15
Eachmodelincludedthehealthconditions,thecovariates,andthe numberofconditionsstartingattwotoavoidcolinearity.Foreach oftheoutcomes,fourmodelswerebuilt(all10countriestogether plusoneforeachregion).
Populationattributablefraction(PAF)asasocietal-levelmeasure PAFs16,17 wereestimated to evaluate theexpected effect of
eitherpreventingorsuccessfullytreatingoneormoreofthehealth conditionsincludedaspredictorsinourregressionequations.PAF canbeinterpretedastheproportionofdayswithfull/partialrole limitation that would not have occurredin theabsence of the predictordisorders.Astheoutcomewascontinuous,the calcula-tionofPAFwasdoneasfollows:thepredictedvalueofahealth conditiononthedependentvariables(i.e.,fullorpartialrole lim-itation)wasdistributedacrossanumberofcoefficientsfromtwo distinctmodels,logisticandGLM.(Moredetailispresentedinthe
SupplementaryBox,intheAppendixonline).
Datawereweightedtoaccountforknownprobabilitiesof selec-tion as well as to restore age and gender distributions of the populationwithincountries.Anadditionalweightwasaddedto restoretherelativedimensionofthepopulationacrosscountries.15
ThestandarderrorswerecalculatedusingtheJackknifeRepeated Replicationmethod,implementedinaSASmacro(SASVersion9.2).
Results
SamplecharacteristicsaredisplayedinTable2.Regionswere similarin genderdistribution(about 50-51%werewomen)and inmeanage(40.2years).Approximatelyonethirdofthe partic-ipants reportednot beingmarriedat thetimeof theinterview (32.2%),withasignificantlylowerproportionofmarried partici-pantsinCentral-EasternEurope(26.8%).Completedhighschoolor morevariedfrom92.7%inCentral-Westerntoonly50%inSouthern Europe.Unemploymentalsovaried:fromthelowestratein Cen-tralWesternEurope(26.5%)tothehighestrateinCentral-Eastern (48.8%).Almostoneintenindividuals(9.5%)reportedafullrole limitationdayandabout18.0%,apartialrolelimitationdayinthe
Table2
Samplecharacteristicsofthepopulationsampleaged18-64yearsintheWMHsurveysinthe10Europeancountries(EU-WMH). N Agemean (se) Females% (se) Notmarried %(se) Highschoolor more%(se) Non-employment% (se)b Anymental disorder%(se) Anyphysical condition%(se) Fullrole limitation% (se)c Partial limitation% (se)c Central-Western 5,493 40.6(0.4) 49.8(1.2) 32.0(1.1) 92.7(0.7) 26.5(1.2) 14.3(0.9) 45.7(1.4) 12.5(0.7) 22.8(0.9) Belgium 863 40.0(0.6) 49.7(2.3) 30.6(1.9) 77.1(3.6) 27.0(1.8) 13.8(1.8) 43.9(2.3) 10.4(1.5) 26.0(2.3) France 1222 39.7(0.5) 50.6(1.9) 26.9(1.7) .(.)a 22.9(1.6) 19.0(1.7) 48.2(2.3) 9.2(1.4) 25.9(1.9) Germany 1097 41.5(0.7) 49.3(1.9) 36.3(1.9) 97.6(0.7) 29.0(2.1) 11.3(1.4) 44.3(2.3) 8.3(1.3) 17.2(1.8) N.Ireland 1387 39.3(0.4) 49.8(1.6) 39.6(2.1) 96.1(0.5) 25.9(1.6) 18.1(1.6) 48.9(2.2) 17.0(1.4) 18.1(1.4) The Netherlands 924 39.6(0.6) 49.3(2.3) 27.4(2.9) 77.6(1.6) 25.8(2.9) 13.5(1.1) 44.9(2.9) 16.1(2.2) 30.2(2.7) Southern 4,780 39.7(0.3) 50.0(1.2) 34.2(1.1) 50.0(1.3) 34.1(1.0) 10.1(0.5) 41.5(1.2) 7.6(0.5) 17.0(0.8) Italy 1466 40.4(0.4) 50.0(1.7) 34.1(1.6) 47.3(2.1) 32.9(1.5) 7.9(0.7) 43.2(1.7) 8.0(1.0) 16.1(1.2) Portugal 1757 40.7(0.4) 50.7(1.6) 31.7(1.4) 62.6(1.5) 28.0(1.2) 21.2(0.9) 48.9(1.7) 8.0(0.7) 17.9(1.2) Spain 1557 38.4(0.5) 49.7(2.0) 35.1(1.8) 49.9(1.7) 37.7(1.9) 9.6(0.9) 36.9(2.0) 7.0(0.8) 17.0(1.8) Eastern 3,393 39.6(0.3) 50.7(1.3) 26.8(1.1) 59.8(1.5) 48.8(1.4) 6.5(0.5) 40.1(1.1) 7.6(0.5) 12.2(0.7) Bulgaria 1682 41.1(0.5) 50.0(1.6) 24.0(2.0) 73.9(1.3) 37.9(1.9) 8.6(0.7) 35.3(1.2) 5.7(0.6) 16.2(1.2) Romania 1711 39.2(0.4) 51.0(1.7) 27.6(1.3) 55.8(1.8) 51.9(1.7) 5.9(0.6) 41.5(1.4) 9.3(0.8) 8.5(0.7) Allcountries 13,666 40.2(0.2) 50.0(0.8) 32.2(0.7) 69.7(0.8) 31.7(0.8) 11.9(0.5) 43.4(0.9) 9.5(0.3) 18.0(0.5) Comparison between countries 3.371 0.103 6.880 139.950 23.158 29.755 6.852 9.036 19.630 X2(pvalue) (.0004) (0.9996) (<0.0001) (<0.0001) (<0.0001) (<0.0001) (<0.0001) (<0.0001) (<0.0001) Comparison between regions 1.937 0.176 12.003 301.939 67.438 27.680 5.061 3.251 9.955 X2(pvalue) (0.1441) (0.8387) (<0.0001) (<0.0001) (<0.0001) (<0.0001) (0.0068) (<0.0001) (<0.0001) N:unweighted;%:weighted.
aEducationinFrancewascollecteddifferentlyfromtheothercountries.
bNon-employeesincludedstudents,unemployed,earlyretirement,permanentlydisabled,fulfillingdomestictasksandcareresponsibility. c Theproportionofindividualsreportingeitherafullorapartialrolelimitationdayinthepreviousmonth.
Figure1.Prevalenceratesand95%ConfidenceIntervalsofhealthconditionsbyEuropeanregions(EU-WMH).
*Otherphysicalconditions:cancer,neurologicaldiseases,diabetes,oranydigestivedisorders(stomachorintestineulcerorirritableboweldisorder). aAllthreeEuropeanregionsshowedstatisticallysignificantdifferencesintheprevalenceofhealthconditions(95%CIdoesnotoverlap).
bCentral-EasternEuropeshowedstatisticallysignificantdifferencesintheprevalenceofhealthconditionsincomparisonwithCentral-WesternandSouthernEurope(95%CI
doesnotoverlap).
cCentral-WesternEuropeshowedstatisticallysignificantdifferencesintheprevalenceofhealthconditionsincomparisonwithSouthernandCentral-EasternEurope(95%CI
doesnotoverlap).
previousmonth.Central-WesternEuropewastheregionwithmore fullandpartialrolelimitationdays.
Abouthalfofthesample(48.2%)hadahealthcondition (Central-Western Europe, 51.1%; Southern, 45.8%; and Central-Eastern Europe,42.7%)(Fig.1).Physicalconditionswerethreetimesmore prevalentthan mentaldisorders (43.9% vs.11.9%, respectively). Prevalenceofmentaldisordersvariedamongregions,from14.3% inCentral-Western,10.1%inSouthern,and6.5%inCentral-Eastern Europe.Regionaldifferenceswereobservedforarthritis (Central-Eastern,22.1%comparedtoCentral-WesternandSouthernEurope). Central-EasternEuropeshowedmarkeddifferences inregardto cardiovasculardiseases as a highlyprevalentcondition (15.1%), andheadache/migraine(6.6%)andchronicpaindisorders(11.5%) aslowprevalenceconditions,incomparisonwiththeothertwo regions.
AsshowninFigure2,about30%ofindividualsreportinghealth conditionshad any role limitation.Among those withany role limitation due to health conditions, around 60% reported par-tial, 15% reported full, and 25% reported both. Role limitation, particularlypartiallimitation,wassignificantlyhigheramong indi-vidualswithanymentaldisorder(43.3%),thanamongthosewitha physicalcondition(29.1%).Mentaldisorderscategoriespresented similarproportionofanyrolelimitation.Amongphysical condi-tions,insomniaandotherphysicalconditionspresentedthehighest
whilecardiovascularandrespiratorythelowestproportionofany rolelimitation.
Figure3showsthePopulationAttributableFraction(PAFs)offull (Fig.3A)andpartial(Fig.3B)rolelimitationforphysicalconditions andmentaldisorders.Intheoverallsample(blackcolumn)thePAFs forallthehealthconditionswere62.6%forfullrolelimitationand 46.6%forpartialrolelimitation.ThisPAFdifferencewasstatistically significantattheoveralllevelbutnotwithintheregions.Figure3
AshowsthatthePAFsoffullrolelimitationweresimilarforboth typesofconditions(physicalandmental).Thiswasalsothecase intwooftheregions,butnotforCentral-EasternEurope(white column)wherethePAFforfullrolelimitationattributabletomental disorderswaslowerthanthatattributabletophysicalconditions. InFigure3Bnostatisticallysignificantdifferenceswereobserved acrossregionsonthecontributionsfromeachtypeofdisorderto partialrolelimitation,again,withtheexceptionofCentral-Eastern Europe.
Table3presentsPAFsoffullandpartialrolelimitationforeach healthconditionandbyregion.Resultsshouldbeinterpretedas follows:of 100%oftherole limitationreportedbyparticipants, depressive disorders contribute to explain 12.7% of full role limitationand12.1%ofpartialrolelimitationinEurope.Overall, anxiety,depression, chronicpain and otherphysical conditions contributedthehighestPAFstofullrolelimitation.Whilechronic
G.Barbagliaetal./GacSanit.2017;31(1):2–10 7
Table3
PopulationattributableFraction(PAF)ofdayswithfullandpartialrolelimitationduetocommonhealthconditionsbyEuropeanregion(EU-WMH).
Total Central-WesternEurope SouthernEurope EasternEurope PAFFull limitation% (se) PAFPartial limitation% (se) PAFFull limitation% (se) PAFPartial limitation% (se) PAFFull limitation% (se) PAFPartial limitation% (se) PAFFull limitation% (se) PAFPartial limitation% (se) Mentaldisorders Depressivedisorder 12.7(2.4)a 12.1(1.7)a 8.9(3.4)a 13.9(2.5)a 24.4(4.2)a 13.8(2.9)a 3.5(4.2) 1.8(2.8) Anyanxiety 19.6(3.9)a 7.6(2.2)a 21.8(5.1)a 4.4(2.9) 16.8(5.5)a 13.6(3.1)a 6.7(3.8) 9.4(3.6)a Physicalconditions Arthritis 5.2(2.8) 8.0(1.9)a 4.6(3.4) 6.2(2.4)a 16.9(5.4)a 14.9(3.2)a -19.3(7.8)a 0.1(2.7) Cardiovascular 4.6(3.2) 2.2(1.6) 1.5(3.4) -1.1(1.5) 3.7(4.8) 5.0(2.8) 17.5(6.1)a 17.5(5.7)a Chronicpain 15.3(3.9)a 14.5(2.8)a 15.6(5.7)a 11.3(3.6)a 12.6(5.4)a 19.2(4.7)a 18.0(5.8)a 19.8(5.0)a Headache/migraine 3.6(2.5) 4.3(1.6)a 2.5(3.1) 3.1(2.1) 5.8(4.7) 4.2(2.8) 12.5(5.4)a 6.5(2.9)a Insomnia 5.5(2.7)a 5.0(1.6)a 7.3(4.7) 6.8(2.3)a 2.1(2.8) 1.4(1.6) 4.6(1.4)a 3.1(1.9) Respiratory -0.4(2.3) 2.5(1.7) 2.0(3.5) 2.0(2.5) -4.8(3.5) 6.7(3.1)a -0.6(3.1) -5.5(1.7)a
Otherphysicalconditions 16.4(3.6)a 3.0(1.2)a 17.9(4.4)a 2.6(1.5) 13.5(3.8)a 0.1(2.2) 12.9(8.2) 8.6(3.3)a
Anymentaldisorder 28.9(3.3)a 18.6(2.4)a,b 27.5(4.7)a 17.4(3.3)a 36.3(4.5)a 25.2(3.4)a 9.8(4.7)a,b 11.7(4.2)a,b
Anyphysicalcondition 41.2(4.3)a 33.9(2.9)a,b 40.8(6.3)a 28.5(4.4)a 42.3(6.0)a 41.3(4.2)a 40.0(7.0)a,b 38.2(4.7)a,b
Anyhealthcondition 62.6(3.7)a 46.6(3.2)a 64.5(5.1)a 45.1(4.9)a 63.6(5.2)a 53.8(3.9)a 45.2(7.3)a 41.5(5.3)a
n:unweighted;%:weighted.
Thesocietalpredictedvaluesforbothoutcomescomefromatwo-partmodellingapproachandwereobtainedbymultiplyingpredictedvaluesofthelogistic(firstpart)and GLM(secondpart)equations.Theestimatesofbothrolelimitationvariableswerecalculatedbasedontheactualdata,andthenunderthecounterfactualassumptionthat theconditionnolongerexisted.
Allmodelsadjustedbyage,sex,employmentstatus,country,maritalstatus,educationandthenumberofconditionsstartingbytwo.
aStatisticalsignificance<0.05.
bStatisticalsignificance<0.05betweenanymentaldisorderandanyphysicalcondition.
Figure3. Fullrolelimitation(A)andpartialrolelimitation(B)expressedas popu-lationattributablefractions(PAFs)byEuropeanregions(EU-WMH).
pain,depression,arthritis,anxiety,insomnia,headache/migraines and other physical conditions had the highest PAFs of partial role limitation. In Central-Western and in Southern Europe, depressionandanxietyweresubstantialcontributorstofullrole limitation.InSouthernEurope,mentaldisordersalsosignificantly contributedtopartialrole limitation.In Central-Eastern Europe almostallphysicalconditions,particularlycardiovasculardiseases andchronicpain,contributedimportantlytofullandpartialrole limitation.Chronicpainwasthehealthconditionthatsubstantially andconsistentlycontributedtofullandtopartialrolelimitation inallEuropeanregions.
Discussion
Ourpaperhasfourmajorfindings.First,abouttwo-thirdsof thetotalfullrolelimitationandaboutone-halfofthepartialrole limitationareassociatedwithninehealthconditions inEurope. Theoretically,role limitationscouldbelargelyreducedby treat-ingorsuccessfullypreventingtheseninehealthconditions.Other burdensome health conditions not included in this study (for instance,hearinglossand visualimpairment),5 as wellas
non-healthrelateddeterminants(work-relatedandnon-workrelated factors18,19)couldcauserolelimitationsleftunexplainedinthis
study. Second,chronic pain wasthe singlecondition that con-tributed the most to both disability measures in all European Regions.Thisis very consistentwiththeGlobalBurdenof Dis-ease Study results,1 in which low back pain is the leading
cause of disabilityin Europe, and withpreviousstudies repor-ting that musculoskeletal conditions, especially back and neck pain,arethemostcommoncauseofphysicaldisabilityinWestern countries.1 Third, regional differences were observed:
depres-sive and anxiety disorders were important contributors tofull and to partialrole limitationin Central-Western and Southern Europe,whileinCentral-EasternEuropecardiovasculardiseases andheadache/migraineweremoreimportantcontributors. Previ-ousstudieshavealsoreportedthatmentaldisordersrepresenta substantialburdeninsomeEuropeancountries20–22andinother
countries.23Andfourth,Central-EasternEuropewastheregionin
whichmentaldisorderscontributedthelowestshareoffulland partialrolelimitation.ThisfindingisincontrastwiththeGBDstudy, whichrankeddepressionasoneofthetenleadingcausesof dis-abilityinBulgariaandinRomania.Reasonsforthisdifferenceare noteasytograspfromourdata,butwespeculatewithpossible explanationsbelow.
Our analysiswasrestricted toapopulationsampleof work-ingageindividuals(18-64years),thus,whilethisisnotasample of workers, full and partial role limitation estimates might be interpretedasproxymeasuresofabsenteeismandpresenteeism, respectively. Accordingly,health conditionshave a much larger impact on absenteeismthan onpresenteeism. Thisis because, in general, other non-healthrelated factors frequentlyaccount forworkperformance.18,19Work-relatedfactors(e.g.,shiftwork,
physicalwork,employmentposition,amongothers)togetherwith nonwork-relatedcharacteristics(e.g.,familylife,financial situa-tion,adverselifeevents,amongothers)havealsobeenshownto berelevantinexplainingworkperformance.Nevertheless,the pro-portionofreducedfunctioningexplainedbycommonandtreatable healthconditionsisfarfromnegligible.Moreover,giventhatpartial disabilitypredictsfuturefulldisability,24ourfindingscarry
impor-tantpolicy-makingimplications.Apreviousstudy25 ofoverone
millionworkersshowedthatthecostofproductivitylosses associ-atedtohealthconditionswouldbeabout40%ofthemedicalcosts generatedbythesamehealthconditions.Thus,reducingtheimpact ofprevalentdisordersshouldbeapriorityinoccupationalhealth policiesinallEuropeanregions.
Chronicpain,anxiety,anddepressionexplainedalmosthalfof allhealth-relatedfullrolelimitationreportedinCentral-Western (46.3%)andinSouthernEurope(53.8%);andchronicpain, cardio-vasculardiseasesandheadache/migrainesdidsoinCentral-Eastern Europe(48.0%).Themostimportantcross-regionaldifferencewas thesmallproportionofdisabilityexplainedbymentaldisordersin Central-EasternEuropeincomparisonwiththeothertworegions. WMHsurveydataarecross-nationallycomparableastheywere assembledusingastandardizedprotocolforsampling, interview-ing,codingandanalysing.15So,itislikelythatthiscross-regional
differencemightbeexplainedbyreasonsotherthan methodologi-calissues.Allhealth conditionsthatsignificantlycontributedto fullrolelimitationinourstudywererespectivelylistedamongthe top-tenhighlydisablingconditionsinthe2010GBDstudy,except formentaldisordersinCentral-EasternEurope.IntermsofDALYs, majordepressivedisordersrankedeighthandsixthasthemost disablingconditioninBulgaria andRomania,respectively. Simi-laritiesanddifferencesbetween2010GBDstudyandWMHhave beenextensivelydiscussed26but,ingeneral,DALYsandPAFsare
population-baseddisabilitymeasuresthatcanbecompared.Itis knownthatprevalenceanddisabilityarenotdirectlycorrelated; inparticular,mentaldisordersareconditionswithlowprevalence butassociatedwithlargelimitationsin functioning.21However,
posthocanalysesofourdata(notpresented)showedasignificantly lowerproportionofpartialrolelimitationinRomaniacomparedto othercountrieswithlowprevalenceofmentaldisorders(Italyand Germany).WespeculatethatspecificculturaltraitsoftheRomani populationcouldaccount forthis difference27,28 thatfostersan
underestimationoffunctionallimitationsassociatedwithhealth conditions.Such underestimationwould leadtounderreporting functionallimitations,resultinginmeasurementbias(i.e.,a pos-sibledifferentialitemfunctioning).Futureresearchshouldaddress thesecountry-specificdifferences inorder toelucidatethetrue burdenofmentaldisordersinCentral-Easterncountries.
Theimpactofco-morbidconditionsonhealthstatusisusually sub-additive.29Thiscouldimplythattoaccomplishamore
substan-tialdecreaseoftheimpactofco-morbidconditionsondisability, allconditions, not only one in particular,should beaddressed. Wetestedthishypothesisbyincludingthenumberofco-morbid conditionsinallmodels.Forfullrolelimitation,thecoefficientof thenumberofco-morbidconditionswasnegativeandstatistically significant,while forpartiallimitation,thecoefficientwas non-significant.Ourresultswouldthereforebeconsistentwithfindings reportedbyAlonsoetal.29Nevertheless,weareawarethatasimple
co-morbiditycounttermisnottheoptimalwayofcontrollingfor co-morbidity:inadditiontoconsiderallco-morbidconditionsat once,aswedidhere,itwouldalsobenecessarytoconsiderwhich co-morbiditypatternsareassociatedtohigherorlowerdecrements inhealth.Apreviousstudy30showedthatdepressionin
combi-nationwithcertainchronicconditions(asthma,diabetes,angina) producedagreaterdecrementinhealththananyofthese condi-tionsaloneordepressionalone.Furtherexplorationofpatternsof chronicconditionsandimpactondisabilityisnecessary.
Limitationsofthestudy
Somelimitations shouldbe taken into account when inter-preting our findings. First, only a limited number of physical conditions and mental disorders wereincludedin theanalysis. Futureresearchshouldincludetheabove-mentionedconditions alongwithanexpansion(e.g.,substanceusedisorders,psychotic disorders) and disaggregation (e.g., anxiety disorders) of those alreadyincluded.Second,whilementaldisorderswereassessed with a well-established measure,12 physical conditions were
self-reported.Althoughthereisevidenceofgoodcorrespondence betweenself-reported31 conditions(diabetes,heart diseaseand
asthma),andclinicalrecords,wemighthaveunderestimatedthe effect of physical conditions on role limitation. Additionally, thecollectionofthedatawasdoneindifferentyearsinsome coun-trieswithinthesameregion,sothismayhavehadaninfluencein thedifferencesobservedbetweenregions.Third,EasternEurope wastheregionwiththelowestprevalenceestimatesofDSM-IV mentaldisordersandalso,asmentionedabove,waswherethe low-estassociationwithdisabilitywasobserved.Suchcross-regional variation in mental disorders prevalenceshouldbe interpreted withcaution.Anextensivediscussiononcross-nationalvariations inprevalenceestimatesofmentaldisordersintheWMHSurveys canbefoundinKessleretal.13Itremainspossiblethatagreater
reluctanceofrespondentsinEasterncountriestoadmitemotional problemstoa stranger.Thisissuewould besupportedbysome evidenceaboutstigmabeingamajorprobleminCentral-Eastern countries.32 It isalsopossiblethat theCIDI wouldnot be
com-pletely adequate to capture psychopathological syndromes in Easterncountries.15Ahighproportionofsub-thresholdcaseswith
psychiatrictreatmentincountrieswithlowprevalenceestimates has been reported.33 This suggests that there is still room for
improvementinthediagnosisofmentaldisorders.Finally,thedata werecollectedbeforethepeakoftherecentfinancialcrisis,which isassociatedwithimportanthealthimpacts.34Changesinhealth
and economic conditions might modify associations described here.Inthis sense,weightingfornon-responsewasdoneusing general characteristics (e.g., age, sex, and country) while non-responseishigheramongthelesseducated,theunemployedand theimmigrantpopulations,characteristicswhichalsoarelinked withpoormentalhealth.Moreover,insomecountries,therewasa lowresponseratethatmayalsohavecontributedtoaselectionbias resultinginconservativeestimatesontherelationship between rolelimitationandphysicalandmentaldiseases.
Conclusions
Notwithstandingtheselimitations,ourresultsarerelevantfor healthpolicy,asmostofthesehealthconditionsaretreatable,sothe largerolelimitationimpactassociatedtothemmightbeavoidable. Theyarealsoimportantforresearch,inparticularaboutthe differ-encesinprevalenceandinassociateddisabilityfoundincountries fromCentral-EasternEurope.
Editorincharge
AlbertoRuano-Ravina.
Transparencydeclaration
Thecorrespondingauthoronbehalfoftheotherauthors guar-antee the accuracy, transparency and honestyof the data and informationcontainedinthestudy,thatnorelevantinformation hasbeenomittedandthatalldiscrepanciesbetweenauthorshave beenadequatelyresolvedanddescribed.
G.Barbagliaetal./GacSanit.2017;31(1):2–10 9
Justificationonthenumberofco-authorsexceedingthe
permittedamount
Thispaperhas14authorsastheWMHConsortium’sagreement specifyinitspublicationpolicytheneedofhavingoneco-author fromeachoftheparticipatingcountries.Thispolicyisbasedonthe crucialcontributiontostudydesign,datacollection,poolingand harmonization,aswellastheirinputinthemanuscriptpreparation.
Whatisknownaboutthetopic?
Chronichealthconditionsareassociatedwithagreatdealof disabilityinEurope.However,disabilityisdifferentlydefined acrosscountries,whichmakescomparisondifficultwiththe consequentproblemsatpolicy-makinglevels.
Whatdoesthisstudyaddtotheliterature?
This study adds information on health-related disability whichiscomparablethroughdifferentEuropeanRegions.We haveconsideredbothpartialaswellasfullrolelimitationdays, providing a full picture of health-related disability. Results showthatthecontributionofmentaldisordersandphysical conditionstodisabilityatworking-agepopulationishighinall theregionsstudied.
Authorshipcontributions
Allauthorshaveparticipatedactivelyinthestudy,andhaveread andapprovedthesubmittedmanuscript.G.Barbaglia,N.D.Adroher, J.AlonsoandG.Vilagutwereinvolvedintheconceptionanddesign ofthestudy,theanalysisandinterpretationofdataandcritically reviewedthemanuscript.G.Barbagliawrotethemanuscript,and N.D.Adroher,G.Vilagut,J.Alonso,S.FlorescuandR.deGraafmade substantialcontributionstoit.R.Bruffaerts,B.Bunting,J.M.Caldas deAlmeida,S.Florescu,G.deGirolamo,R.deGraaf,J.M.Haro,H. Hinkov,V.Kovess-MasfetyandH.Matschingerparticipatedinthe acquisitionofdata,criticallyreviewedthemanuscriptandprovided finalapprovalforthemanuscriptsubmitted.
Acknowledgements
The ESEMeD project is funded by the European Commis-sion (contracts QLG5-1999-01042; SANCO 2004123 and EAHC 20081308),thePiedmontRegion (Italy),FondodeInvestigación Sanitaria,InstitutodeSaludCarlosIII,Spain(FIS00/0028), Ministe-riodeCienciayTecnología,Spain(SAF2000-158-CE),Departament deSalut,GeneralitatdeCatalunya,Spain,InstitutodeSaludCarlos III(CIBERCB06/02/0046,RETICSRD06/0011REM-TAP),andother localagenciesandbyanunrestrictededucationalgrantfrom Glax-oSmithKline.
We thank the WMH staff for their assistance with instru-mentation, fieldwork, and data analysis. A complete list of WMH funding support and publications can be found at:
http://www.hcp.med.harvard.edu/wmh.
Funding
ThisworkwassupportedbytheEuropeanCommission [QLG5-1999-01042, SANCO 2004123, EAHC 20081308], the Piedmont Region (Italy), Fondo de Investigación Sanitaria, Instituto de SaludCarlosIII, Spain[FIS00/0028-02], Ministeriode Cienciay
Tecnología,Spain[SAF2000-158-CE],DepartamentdeSalut, Gen-eralitatdeCatalunya,Spain[AGAUR2014SGR748AGAUR2009 SGR1095],andotherlocalagenciesandbyanunrestricted edu-cationalgrant fromGlaxoSmithKline. ESEMeD is carried out in conjunction withtheWorld Health OrganizationWorld Mental Health(WMH)Survey.G.BarbagliawassupportedbyMinisteriode CienciaeInnovaciónRioHortegagrant[CM10-00099].Nofunding bodieshadanyroleinstudydesign,datacollectionandanalysis, decisiontopublish,orpreparationofthemanuscript.
Conflictsofinterests
None.
AppendixA. Supplementarydata
Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,atdoi:10.1016/j.gaceta.2016.07.008.
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