COURAGE in Europe was a three-year project involving 12 partners from 4 European countries and the World Health Organization. It was inspired by the pressing need to integrate international studies on disability and ageing in light of an innovative perspective based on a validated data-collection protocol. COURAGE in Europe Project collected data on the determinants of health and disability in an ageing population, with specific tools for the evaluation of the role of the built environment and social networks on health, disability, quality of life and well-being. The main survey was conducted by partners in Finland, Poland and Spain where the survey was administered to a sample of 10800 persons, and was completed in March 2012. The newly developed and validated COURAGE Protocol for Ageing Studies has proven to be a valid tool for collecting comparable data in ageing population and understanding and better measuring health, disability, quality of life and well-being and the role of health in promoting these, across the life course.
The COURAGE in Europe Project has thus created valid and reliable scientific evidence, demonstrating cross-country comparability, for disability and ageing research and policy development, and allowed to recognise how well-being and quality of life change over time and with age, and how they are affected by changing health, and factors like environment and social networks. It is therefore recommended that future studies exploring well-being, quality of life and determinants of health, disability in ageing use the COURAGE-derived methodology and protocol.
Background and European concerns
The increase in the proportion of older people in Europe is the result of unprecedented economic, social, medical and technological changes that have made it possible to live a long and active life. In Europe, the percentage of persons older than 60 was 20.3% (3.0 for 80+) in 2000, but will rise to 28.8% (5.2% for 80+) in 2025, while the median age will rise from 37.7 to 45.4: the old age dependency ratio (i.e. the number of persons 65+ per one hundred persons 15-64) will rise from 21.7 to 33.2 (United Nations, 2002).
Although these trends are fairly well understood, the political and social changes that they will produce are less so. Either future populations may live long and active lives, with severe disability occurring only at the very end of life – a phenomenon called ‘compression of morbidity’ (Fries, 2003) - or they will experience increasingly high prevalence of mild and moderate disability for a longer period – a phenomenon called ‘expansion of morbidity’ (Scheider & Brody, 1983). Both these ageing scenarios have huge, but very different, political and social consequences. If compression of morbidity is true, then we should expect that people could work longer contributing through taxation to help pay health and other social expenses as well as concentrating a large amount of health costs in few years. If, instead, expansion of morbidity is true, then the overall health and social costs will be far higher in health, rehabilitation and assistive technology services and will affect employment, transportation and other policy areas. The evidence concerning the two ageing scenarios is conflicting, but data show that the prevalence of most chronic diseases (neurological and psychiatric conditions, arthritis, heart problems, diabetes, hypertension and obesity) and their associated risk factors has increased in developed countries (Lafortune, Balestat & the Disability Study Expert Group Members, 2007). The last update of the Global Burden of Disease Study (GBD), released in 2012 (Murray et al., 2012) showed an increase in Disability-Adjusted Life Years (DALYs) in adult populations, with a particular impact of chronic conditions such as Ischemic Heart Disease, Stroke, Low Back Pain, Depression, Diabetes and other mental, neurological and non-communicable diseases.
Because of these trends, the European Commission in 2006 identified population ageing as one of the most challenging policy issues of the 21st century (European Commission, 2006). Valid and reliable outcome measures for good statistics and innovative measurement instruments for cross-population comparative analyses are needed, as previous ageing studies involving persons aged 50+ tended to confuse the relationships between a person’s health state and his/her quality of life and well-being, relying on measures with limited validity. This confusion is due to overlapping research questions and to a conflation of subjective and objective perspectives. As a result there was and still is a need to measure these elements independently and against the background of the framework of health and disability provided by WHO’s International Classification of Functioning, Disability and Health – ICF (World Health Organization, 2001), that defines disability as the interaction of a health condition with contextual factors (Leonardi, Bickenbach, Ustun, Kostanjsek, Chatterji, & the MHADIE Consortium, 2006). The COURAGE in Europe project was designed to respond to these pressing needs.
The COURAGE in Europe project aimed to provide cross-population analysis and a baseline for longitudinal data collection. The methodology made it possible to produce comparable cross-population analyses of non-fatal mental and physical health outcomes, quality of life, and well-being in ageing.
Project fieldwork was carried out in the three countries, resulting in representative sample of 1,042 persons aged 18-50 and 3,029 aged 50+ (4071 in total) in Poland, 962 persons aged 18-49 and 3,791 aged 50+ (4753 in total) in Spain, 485 persons aged 18-49 and 1491 aged 50+ (1976 in total), in Finland. The fieldwork was completed in March 2012. Mean unweighted age was 59.27 for Finland, 57.62 for Poland and 60.44 for Spain.
A trend of increase in functioning difficulties with age and with levels of household wealth was observed for the whole sample, with older subjects and those with lower wealth reporting more difficulties in ADLs, IADLs and higher disability assessed with the WHODAS 2. An inverse relationship between health state and age was observed, with older subjects showing lower health and worst functioning. Differences among countries were also observed: respondents from Poland reported worse scores than those from Spain and Finland, which reported fewer difficulties in ADL and IADL and in disability scores. Regarding mobility functions, for Poland difficulties in walking 1 kilometre were much more common (56%) than in Finland (27%) and Spain (32%). Also, the prevalence of risk factors and their association with mobility limitations varied considerably between the three countries.
Quality of life, collected with the newly developed and validated instrument WHOQoL-AGE, was perceived as better in Finland 77.14 (s.e. = 0.29) and in Spain 72.21 (s.e. = 0.26) than in Poland 65.04 (s.e. = 0.33). The levels of quality of life decrease with age, and in Poland this decrease is more pronounced (Figure A). Quality of life was higher with increased income.
The COURAGE in Europe Project collected data on health, quality of life, well-being and on the determinants of health and disability in an ageing population, with specific tools for the evaluation of the role of built environment and social networks on health, disability quality of life and well-being. The developed and validated COURAGE Protocol for Ageing Studies has proven to be a valid tool for collecting comparable data in ageing populations and the COURAGE in Europe Project created valid and reliable, and cross-country comparable, scientific evidence for disability and ageing research and policy development. Project results allow to recognise how well-being and quality of life change overtime and with age, and how they are affected by changing health, and factors like environment and social networks. It is therefore recommended that future studies exploring determinants of health and disability in ageing as well as the effects of ageing on well-being and quality of life use the COURAGE Protocol and the project derived methodology.
An aspect of particular interest in the COURAGE in Europe Project’s research is that targeted environmental factors, namely the built environment and social network, can be modified with appropriate interventions. The knowledge of connections between objective health status and subjective dimensions as quality of life and well-being, measured with appropriate instruments, will enable policy makers to expand the range of possible actions that address the problem of ageing in Europe. Social policy, for example, should focus on maintaining the existing, and developing new social networks among people in older age. People should intensify, or should be helped to intensify, their social networks which COURAGE proved to be an element that can help to preserve their health, and there are several possible elements that impact on social network, such as the built environment, that should be taken into consideration for policy development. The impact of COURAGE in Europe affects both the collection of data and the production of a valid methodology that could be used in all countries for creating a European database on ageing and relevant elements such as functioning, well-being and quality of life of populations.
The project in fact also increased our understanding of the effects of ageing on well-being and allowed for the analysis of the effects of social and policy changes on ageing. Finally, because it showed a relationship between health and socio-economic status, health and well-being, and provided measures of environmental determinants to explain variation between countries (and in particular the North-South gradient), COURAGE in Europe results and methodology can support European States in the reorganization of their health and welfare systems so as to further implement the principles of equity, solidarity and universality.