9. STATE OF HEALTH AND SELECTED PARAMETERS OF DEMOGRAPHIC AND HEALTH STATISTICS |
9.1 Monitoring the population’s health status
The monitoring of the population’s health status is based on a questionnaire survey titled the HELEN Study (Health, Life Style and Environment).
The objective of the HELEN Study is to supplement data of routine demographic and health statistics with further indicators of health and to estimate the prevalence of selected noninfectious diseases and risk factors of those diseases in the urban population of the Czech Republic. Determined are also selected socio-economic and psychosocial characteristics and indicators of the lifestyle of the respondents. Further, there are evaluated the opinions among the inhabitants of the participating localities on the quality of the environment at site of residence with a follow-up of their standpoint on problems of lifestyle and health. The data are evaluated as a whole as well as separately for each city.
Following the pilot study in 1997 (Karviná, Kolín), in the years 1998 to 2002 the first stage of the HELEN Study was carried out in a total of 27 cities in the Czech Republic included in the Monitoring System (see technical report on Subsystem VI for the year 2003).
The second stage of the survey, i.e. a repeated survey, applying the same methodology, took place in the same cities in 2004 (Brno, České Budějovice, Hradec Králové, Karviná Kladno, Most, Olomouc, Plzeň, and Žďár nad Sázavou) and continued in 2005 (Liberec, Jablonec nad Nisou, Ústí nad Labem, Děčín, Mělník, Příbram, Klatovy, Jihlava, Havlíčkův Brod, Svitavy, Ústí nad Orlicí, Znojmo, Šumperk, Kroměříž, Ostrava, Prague 10).
9.1.1 Organization of the survey and the structure of the questionnaire
Through a systematic random selection ensuring that the sample is representative, there have been selected 800 subjects in each city (400 males and 400 females) of the 45–54 years age group. The population register served as the basis of the systematic random selection. The selected subjects at first received an informing letter and then were contacted by an investigator.
The HELEN Study included a medical check-up to which half of the subjects contacted (200 males and 200 females in each city) were invited. The examination took place at the Public Health Institutes and was organized by their staff. The examination included repeated taking of blood pressure, taking of body height and mass, waist and hip circumferences, and the determination of total blood cholesterol. The methodology in the study, including the physical check-up, has been presented in the Manual for the HELEN Survey (see technical report on Subsystem VI for the year 1999).
The structure of the questionnaire was designed in 1998 (first stage of the survey), in the second stage it has been supplemented with questions concerning physical activity and questions on dietary habits have been altered. The questionnaire consisted of 70 questions and was divided into the following sections:
9.1.2 Respondency rate and structure of the series in stage II (preliminary results)
The questionnaire was completed by a total of 9,222 respondents (45.5 % males, 54.5 % females); the questionnaire returnability was 49.8 %, ranging from 29.5 % in Klatovy to 66.7 % in Karviná. A total of 1,842 individuals underwent medical check-ups, the respondency rate of the probands being 20.4 %. The lowest attendance rate at medical check-ups was in Kladno (4.8 %), the highest in Karviná (52.1 %) (Fig. 9.1a).
9.1.3 Comparison of data on health found in the questionnaire survey with the documentation of general practitioners
Part and parcel of the second stage of the HELEN Study in 2004 was the comparison of data given by respondents in the questionnaire with data from documentation at their GPs. The objective of that validation was to determine whether and how the respondents’ replies differ from information extracted from GP documentation regarding of diseases under follow-up and thus to verify the reliability of the results of the study.
Subjects selected for inclusion in the study have been, besides the filling-in of the questionnaire, asked to sign a paper of consent for looking into their medical documentation. A total of 2,162 subjects were asked for consent. Only 404 subjects had signed it, that being 19 % of all approached and 31 % of those who handed in the filled-in questionnaire. Of those giving consent, 160 have been randomly selected in whom the validation was consequently carried out. That number had been derived from the requirement for reaching the required precision of results and also corresponded to the organizational capability of the Institutes of Public Health involved. GPs of the selected subjects were asked to fill in forms for extracts from the documentation. The form corresponded with the HELEN Survey questionnaire, containing questions on selected diseases as well as on the overall evaluation of the respondent’s health.
The data were expressed in the form of a square contingency table into which the individuals were classified on the basis of their own replies and on data from their GPs. The agreement of data obtained from the respondent (in the questionnaire) with those in the documentation of his/her GP was appraised with the aid of the coefficient of agreement kappa and described are the percentage of agreement achieved, the percentage of expected agreement and the coefficient kappa (Tab. 9.1). The percentage of agreement attained is to a significant degree influenced by the distribution of replies in each category (in this case by the number of cases of each disease), and therefore, it cannot be evaluated as a separate indicator. The percentage of expected agreement indicates what agreement would be attained with entirely random replies. The coefficient kappa then indicates the magnitude of agreement attained upon the removal of the effect of any expected agreement. It indicates what proportion of the maximum possible agreement exceeding the framework of agree by chance has been attained. Kappa greater than 0 indicates a better agreement than the expected one, and the maximum value of the coefficient (kappa = 1.0) reflects a perfect agreement in the replies. Kappa equals 0 indicates that agreement equals the expected one; and kappa lesser than 0 indicates that agreement is lesser than the one expected in chance placing of replies. In as kappa in the absolute majority of medical applications is used in situations in which the agreement of rating is significantly greater statistically than by chance (and that is also the case in the HELEN Study), the primary aim of using the kappa coefficient test is not its difference from 0. In question is foremost the application of kappa as an indicator of the magnitude of agreement. For those ends, values of kappa lesser than 0.4 are considered to be reflecting a low degree of agreement; values in the range of 0.4–0.6 being average; and those over 0.6 reflecting good agreement.
A low degree of agreement was found in the replies of GPs and respondents in allergic diseases including bronchial asthma and hay fever, in chronic anxiety and depression, in eczemas and chronic dermal affections, and in chronic bronchitis (Fig. 9.1b). In other diseases there was an at least moderate degree of agreement, the coefficient kappa being greater than 0.5 namely in hypertension, tumor diseases, ischemic heart disease, and in affections of the thyroid gland. The best degree of agreement was in gastro-duodenal ulcers (kappa = 0.6), diabetes mellitus (kappa = 0.9) and stroke (kappa = 1.0).
In the assessment of general health there was found a very low degree of agreement (kappa = 0.03). In a great majority of cases the respondents rated their health as being worse than in the rating by the GPs. Only 16 of 160 respondents considered their state of health to be better than has been rated by their GPs; 93 respondents presented a worse rating than their GPs (in 10 subjects the difference was by 2 categories of five possible ones).
In judging the results one has to keep in mind that the documentation at the GPs is not always fully complete and without fault, and that only 30 % of the subjects filling in the basic HELEN questionnaire gave consent to the looking into their medical records. The respondents’ replies are biased by a greater of lesser degree of subjectivity and their effort to protect their privacy. The differences found can be attributed in some cases to that the respondents turn directly to specialists not always informing their GP (skin diseases, chronic anxiety and depression). Other times in question may be the unwillingness of the respondents to name all their complaints or an inexact knowledge of their diagnosis (tumor diseases, ischemic heart disease, high blood pressure). In chronic bronchitis there has most probably been projected into the degree of agreement found, the fact that the GPs were being asked directly with regard to this diagnosis, whereas the respondents had to check out three anamnestic data on that item. Symptoms of chronic bronchitis were considered cough in the majority of days over a period of at least 3 months of the year, the coughing out of sputum the majority of days in at least 3 months of the year, and the duration of those complaints for more than 2 years. The differences noted in spine and joints disorders (mentioned more frequently by the GPs) could have been caused by that some respondents did not mention those complaints because they did not happen to be feeling any pain at the time of filling in of the questionnaire.
In the case of the overall rating of health, the difference found between
the viewpoint of the GP and that of the respondents is not surprising. One
of the reasons is the professional view of the GPs who are focused foremost
on physical complaints, while in rating our own health we are also influenced by our
psychic and social well-being. Moreover, one has to assume that the questionnaire
respondents rate their own health as compared to that of others in their
neighbourhood, while GPs can compare a given person rather with other patients
at their office.
9.2 Selected indicators of demographic and health statistics
Within the framework of regular presentations of selected indicators of demographic and health statistics there have been updated data concerning life expectancy and the incidence of congenital defects. In the part dealing with life expectancy the data have been adopted from publications and databases of the Czech Statistical Office, Eurostat and WHO; in the part dealing with congenital defects those were adopted from materials of the Institute of Health Information and Statistics in the Czech Republic (ÚZIS 1994–2005).
9.2.1 Life expectancy
9.2.1.1 Methodology
Life expectancy is one of the indicators of mortality, which is also used as an indicator of the degree of advancement, of the socio-economic degree of development of society, or of population health. In question is a synthetic indicator that is based on specific death rates (by age and sex) in the actual population, i.e. on the ratio of dead and living in each age group. Simply, life expectation is an estimate of the mean number of years that a given person can live if there be preserved the present mortality rates till the end of one’s life. Most often we can encounter life expectancy at birth (e0) and life expectancy at 60 and 65 years of age (e60, e65), that being calculated for whatever age. In as life expectancy figures differ significantly between genders, mostly this indicator is assessed for males and females separately.
9.2.1.2 Trends in life expectancy in the Czech Republic,
Over the past fifty years, life expectancy increased in males by 14.5 years, in females by 15.9 years. Since WWII the trends in mean life expectancy was not uniform, those 50 years can be divided into three major stages in the developmental trend in mortality levels.
Over the first period mortality levels for both genders decreased rapidly. That period lasted roughly till middle 1960s and life expectancy for both genders in our country was comparable to that in the developed countries of Western Europe. The next period was characterized by a stagnation in life expectancy at birth, and even in middle-aged and advanced age in males by an increased mortality levels. In females that negative phenomenon did not appear, however, the decrease in specific mortality rates continued very slowly. Up to the year 1987, life expectancy at birth in females increased by only 1.7 years. Thus, in that period there came about a growing difference in life expectancy between the genders. From 1960 to 1990 that difference increased by two years (1960 – 5.8 years; 1990 – 7.8 years). That unfavourable situation in the trend of mortality was caused by the bad state of health of the population as a result of the population’s lifestyle with insufficient care for one’s own health, insufficient information, low supply of high-quality foodstuffs, damaged environment, and worsened health care due to inadequate facilities and equipment in the majority of healthcare facilities.
A turn towards a more favourable development1 after 1990 is apparent from Fig. 9.2a and Fig. 9.2b. The introduction of modern therapeutic methods, better availability of pharmaceutics and better professional care, availability of higher quality foodstuffs, more rational nutrition and a change in lifestyle in a section of the population, and a decrease in infant mortality have led to an increase in life expectancy. In males, in view of the worse trend over the previous period, life expectancy increased more rapidly than in females, and thus there has begun a decrease in the significant difference in life expectancy between the genders. Life expectancy in the year 2005 was in a just born-male 72.9 years and in a just-born female 79.1 years. In 2005 life expectancy at 60 has reached 17.8 years in males and 21.7 years in females.
1 In the majority of countries in Central and Eastern Europe during the
socio-economic transformation in the 1990s there has increased the mortality
level resulting in a decline in life expectancy; the Czech Republic, Slovakia
and Poland being an exception.
Excessive mortality in males (difference between the age-specific mortality rate between the genders) is also reflected in the lesser life expectancy in males. That is a phenomenon characteristic not only of all EU countries, but for the majority of countries of the world as well. Just a few countries where there prevail unfavourable cultural and social conditions for females have excessive female mortality. Certain trends can be observed in the development of differences in life expectancy between the genders. Characteristic of developed countries is the decline in that differential through the elimination of premature deaths in males2. In countries with the greatest life expectancy there is taking place a decline in the difference in the life expectancy of males and females. In the Czech Republic, since the early 1990s there is also taking place a decline in the difference in the mean life expectancy between males and females. In the year 2005, that difference was 6.2 years at e0, and 3.9 years at the age of 60.
2 Trovato, F., Lalu, N. M.: A Continuing Pattern of Decline of the Sex Differential
in Life Expectancy in Canada: Early 1970s – Late 1990s. 2005, p. 61.
9.2.1.3 The contribution of mortality change at each age group in the total change of life expectancy over the years 1990 through 2005
Between 1990 and 2005 life expectancy at birth increased by 5.3 years in males and by 3.7 years in females. In that increase there have participated the separate age groups to a varying magnitude (Fig. 9.3a and Fig. 9.3b). The sum of individual columns or contributions of the age groups gives the figure of the difference between life expectancy in the final and initial years (5.3 years, 3.7 years). In males this increase was caused by the decline in the level of mortality in all age groups, foremost among the middle-aged and elderly (35–84 years). In females there was a decline in the mortality level in all age groups of up to 94 years of age, in females over 95 the increase was insignificant. The increase in life expectancy in females was caused foremost by a decline in mortality in the age groups of 55–84 years of age. In Fig. 9.3c there are presented the contributions of each age group to the differences in life expectancy (e0) in the year 2005. The difference in that year was 6.22 years and the highest excessive mortality in males or the higher intensity in mortality in males is apparent at the age of 50–79 years. The greatest differences in the mortality level between the genders were in the age groups of 60–64 years that contributed to the greater life expectancy in females in 2005 almost by one year.
9.2.1.4 Regional differences in life expectancy in the years 2004–2005, (NUTS 3)
Life expectancy figures in the regions (NUTS 3) have been processed by the Czech Statistical Office (ČSÚ) for a two-year aggregate period to prevent chance fluctuation of small numbers. Between the regions the differences in life expectancy are not as great as at lower administrative levels, i.e. between the districts or cities. The greatest life expectancy at birth in 2004–2005 was in Prague, in males as well as in females. Life expectancy in males was 74.7 years and 80.0 years in females. On the other hand, the lowest life expectancy at birth was in the Ústí nad Labem Region, in males by 2.1 years and in females by 1.8 years lower in comparison to figures for the whole of the Czech Republic. Other regions with a mortality intensity higher than in the Czech Republic as a whole are the Moravia-Silesian, Karlovy Vary and Central Bohemian Regions (see Fig. 9.4). Differences in life expectancy at birth between the genders in the separate administrative regions ranged from 5.3 years in Prague to 7.7 years in the Zlín Region where the life expectancy of females is above-average and that of males is below the nationwide average.
9.2.1.5 Life expectancy in EU countries and in selected countries of Europe
Life expectancy greatly differs from country to country world over. In 2004, life expectancy at the level of nationwide populations ranged from 35 years in Botswana to 82 years in Japan. Japanese women had the highest life expectancy of 85 years in that year. In Europe (in the framework of EU25)
the figures for life expectancy in 2003 ranged in males from 65.7 years (Lithuania) to 77.9 (Sweden) and in females from 75.9 years (Lithuania) to 83.6 years (Spain)3. The average value of this indicator for the population of EU25 was 75.1 years for males and 81.2 years in females (at the age of 60 that was 19.5 years in males and 23.9 years in females). Of the European countries rated (Fig. 9.5a, Fig. 9.5b) males in Iceland, Switzerland, Sweden and Norway had the highest life expectancy in 2003. The life expectancy in those countries exceeded 77 years. In females besides already mentioned Spain, the highest life expectancy was in Switzerland, France, Iceland, Sweden and Italy. In those countries life expectancy at birth exceeded 82 years. On the other hand, the lowest figures for e0 were calculated for males in the Baltic countries where these values were below 67 years. The lowest life expectancy at birth was in females in Turkey where it was below 71 years. In Fig. 9.5c there is also presented the gender differential in life expectancy. A markedly excessive male mortality is apparent in the Baltic countries and is explained by the risky behaviour and different lifestyle of males in that region. In Estonia, due to the differing mortality intensity between the genders the difference in life expectancy is over 11 years. As has been mentioned above, the diminishing of the difference in life expectancy is characteristic of developed countries. Small differences between the genders in this indicator, in 2003, were in Iceland, Malta, Cyprus and in Great Britain. The lowest difference in this case, however, was in Turkey, namely 2.3 years – that small difference being ascribed rather to the social rank of women in society.
9.2.1.6 Healthy life expectancy
The past century was a period of a marked prolongation of the life of human beings. In a number of developed countries life expectancy at birth has exceeded 80 years. There have occurred substantial changes in the level of mortality and in the relative frequencies in causes of death. To the forefront of scientific interest there have advanced problems relating to longevity, chronic diseases, and the quality of life. There is ever more often being manifested the endeavour to grasp qualitative changes in the prolongation of human life. That endeavour has led to the creation of new indicators such as the healthy life expectancy (healthy-adjusted life expectancy, disability-free life expectancy etc.) combining the processes of mortality and morbidity4. The indicator is thus an estimate of life expectancy in full health.
3 In 2003, in our country the figures for life expectancy at birth were
72.1 years (males) and 78.7 years (females); at the age of 60 that was 17.3
and 21.4 years, respectively. Eurostat.
4 For calculations, most often there is applied the so-called Sullivan method
combining mortality life tables and the momentary measure of prevalence
found through sample survey.
Figure 9.6 presents the healthy-adjusted life expectancy (HALE) in selected European countries. There exist certain relations between the level of development of a country and HALE. People in developed countries not only live longer, but also survive a relatively longer period of life in health than populations in less developed countries. The difference in HALE between females and males is lesser than in life expectancy as such. Although females live longer years in health than males, they live in health a smaller portion of their lives. In the Czech Republic healthy-adjusted life expectancy (HALE) has been estimated by the WHO in 2001 to be 63.8 years in males and 69.5 years in females. Thus, males live 11.3 % and females 11.8 % of their lives in some illness.
9.2.2 Congenital defects
Data on congenital defects have been processed over a period of 23 years, from 1981 through 2003. There is presented the relative number of live-born children with a congenital defect per 10,000 live- borns. In question are children in whom the congenital defect has been diagnosed under one year of age. There have been retained yearly intervals for the data; there are presented the numbers of boys and girls and the overall numbers (Fig. 9.7a).
In 2003 the relative number of live-born children with congenital defect in males reached 455.4, in females 356.7, and overall 407.7 per 10,000 live-borns. There is apparent an increase in the relative number of children with congenital defect in the years 1994 through 2000. The marked increase between 1999 and 2000 can be explained to a large degree by a change in the methodology of data collection. Since 2000 in the assessment there are included even children on whose behalf there has not been handed in the form Notification of congenital defect but the disorder was disclosed in the form Report on a Newborn (e.g., in 2002 there were 16 % of such children). The increase in the number of children with defect that occurred between 1994 and 1999 can in part be explained by improved diagnostics, foremost ultrasound and new genetics methodology.
Of the reported defects there have been selected the most important groups
of congenital defects caused by embryotoxic effect on the embryo. The occurrence
of congenital defects included in the separate groups is expressed as the
percentage of the total number of children with a congenital defect (Fig. 9.7b).
Over the whole period of follow-up, of the selected groups of congenital
defects the most frequent were congenital heart defects, in second and third
place there were defects of limbs and defect of urogenital system; those
were followed by facial cleft and defects of the central nervous system;
the least frequent being defects of the eye.
9.3 Partial conclusions
The respondence rate in the second stage of the HELEN Study did not reach 50 %. In the framework of this study there have been compared data on selected diseases mentioned by the respondents in the questionnaire with those in the documentation by their GPs (so-called data validation). In the majority of diseases compared the degree of agreement between replies from the respondents and their GPs was moderate or good. A low degree of agreement was in diseases in which there can be expected direct treatment by respective specialists. Notwithstanding the differences found, it seems that the data from the questionnaire are well informative and provide relevant information on the prevalence of a majority of the diseases under follow-up, while at the same time allowing in certain cases a more detailed interpretation of the results. In the assessment of overall health, as expected, there was found a very low degree of agreement between the assessment by respondents and that by respective general practitioners, the respondents considering their own health to be worse than their GPs’ view of their problems.
In the year 2005 life expectancy at birth in the Czech Republic has reached 72.9 years in males and 79.1 years for females. Although after three years of stagnation there has again occurred a decline in the level of mortality and thus in an increase in life expectancy, in comparison with countries of so-called Western Europe the Czech Republic still lags somewhat behind. Since the early 1990s mean life expectancy (e0) has increased by 5.3 years in males and by 3.7 years in females; the elderly live longer and there has decreased the difference in life expectancy between males and females. The greatest share in the prolongation of life can be ascribed to the decrease in the level of mortality in middle-aged and elderly males (35–84 years) and in females in the 55–84 year age groups.
In the year 2003, the relative number of live-born children with congenital
defect diagnosed under one year of age has reached 407.4 per 10,000 live-borns.
From 1994 through 2000, that number increased, that in part being explained
by improved diagnostics of those defects and there has to be kept in mind a
change in the methodology of data collection. Over the whole period of
follow-up, congenital heart defects were the most frequent of the groups
of congenital defects selected for follow-up.
Tab. 9.1 Degree of agreement in data on health (agreement of data from the respondent with those in the GP’s documentation)
Monitored diseases |
Coefficient kappa |
Proportion of observed |
Proportion of expected |
Suspect chronic bronchis |
0.1111 |
87.74 |
86.21 |
Chronic anxiety and depression |
0.2199 |
89.81 |
86.94 |
Asthma |
0.2698 |
96.82 |
95.64 |
Hay fewer |
0.3099 |
94.90 |
92.62 |
Eczemas and chronic skin diseases |
0.3628 |
92.31 |
87.93 |
Allergic dieases |
0.3688 |
85.81 |
77.52 |
Affections of the spinal column and joints |
0.4359 |
72.90 |
51.97 |
Hypercholesterolemia |
0.4508 |
73.58 |
51.09 |
Renal calculi |
0.4660 |
93.63 |
88.07 |
Myocardial infarction (MI) |
0.4935 |
98.72 |
97.47 |
Tumor diseases |
0.5109 |
95.54 |
90.88 |
IHD (incl. MI) |
0.5510 |
96.10 |
91.32 |
Increased blood pressure |
0.5772 |
82.39 |
58.35 |
Thyroid gland |
0.5989 |
96.82 |
92.06 |
GIT ulcers |
0.6079 |
95.54 |
88.67 |
Diabetes mellitus |
0.8822 |
98.73 |
89.26 |
Stroke |
1.0000 |
100.00 |
97.47 |