Towards capability-adjusted life years in public health and social welfare: Results from a Swedish survey on ranking capabilities.

INTRODUCTION: The aim of this study was to rank capabilities and suggest a relevant set of capabilities for the Swedish context to inform the development of capability-adjusted life years (CALYs). CALYs is a quality of life measure for policy making based on the capability approach by Amartya Sen.
MATERIALS AND METHODS: A Swedish governmental review proposed the following 10 relevant capabilities: time, financial situation, mental/physical health, political resources, knowledge, living environment, occupation, social relations, security, and housing. Researchers in health-related disciplines from 5 universities ranked these capabilities from 1 to 10 (most to least important) in a web-based cross-sectional survey; 115 of 171 responses were eligible.
RESULTS: Health, social relations, and financial situation were deemed most important. Stratification by gender, research field, and age group revealed few differences. We found that it was possible to rank capabilities and that health, social relations, and financial situation were ranked highest by a non-representative sample of researchers and doctoral students from health-related disciplines at five Swedish universities.
CONCLUSIONS: The revealed ranking is dependent on the metric and must be further explored. The findings support continued development of CALYs for monitoring and evaluating outcomes in public health and social-welfare interventions.

Introduction

Background

Monitoring and evaluation within the areas of public health and social welfare involve conceptual and analytical challenges. In theory, cost-benefit analyses based on willingness-to pay (WTP) can be used for evaluating diverse outcomes and even comparisons between sectors, as in principle, all positive and negative outcomes will influence the stated WTP. However, WTP studies are very rare. Instead, in evaluations with a societal perspective, the estimation of productivity gains and changes in resource use are most common. For sectorial perspectives such as health care or social care, often only changes in resource use are included. Sometimes cost-effectiveness analyses or cost-utility analyses based on quality-adjusted life years (QALYs) are used when evaluating intersectoral public health interventions [1, 2].

Yet, the intrinsic value of education or employment [1-3] or non-health benefits of lifestyle behavior change are not properly captured in QALYs [4], and current evaluation approaches may also omit equity aspects [1, 3, 5]. Therefore, we launched capability-adjusted life years (CALYs), a measure that takes into consideration a broad range of capabilities, as outlined in our commentary [6]. In this study, we take one of the initial steps towards developing CALYs.

Theoretical issues

According to the welfarist framework, welfare (or utility) should be the outcome of interest when assessing the benefits of societal resource allocations [7]. Welfarism is appealing because of the multi-characteristics of public health and social interventions, but the impossibility of making interpersonal comparisons and the difficulty of attaching monetary values to welfare gains continue to hinder its usefulness in applications. Another limitation is that individuals may adapt to the lack of vital necessities and, hence, appear to be quite fine based on self-assessed welfare, when arguably they are not [8].

These limitations led to the development of the framework of extra-welfarism, which is based on the idea that additional information is needed for guiding societal policies [9, 10]. For example, according to Sen, the most important information to consider is capabilities, which refer to the opportunities to achieve a flourishing life according to an individual’s own wishes [11, 12].

An application of extra-welfarism in health economics are QALYs whereby health care interventions are judged by their impact on health [13, 14]. The QALY concept entails adding up lifetime that is weighted between 0 (death) and 1 (full health), and to use this weighted-lifetime as an outcome measure when calculating cost-effectiveness (cost per QALY) of health care and public health interventions [14]. Prominent examples include the different EQ-5D questionnaires that measure health-related outcomes in 5 attributes and 3 to 5 levels, which form combinations of health profiles with associated quality weights. The quality weights for EQ5D measures are derived from information about trade-offs between the different health profiles, usually gathered in setting-specific valuation studies [14].

The focus on health as opposed to utility and allowing interpersonal comparisons are defining extra-welfarist properties of QALYs [15]. Due to the extra-welfarist nature, the QALY concept is in theory not restricted to measuring health benefits but in practice is used mostly to evaluate health consequences. Cookson [16] suggested a ‘capability QALY’ interpretation of QALYs as a ‘cardinal index of an individual’s capability set’. We see CALYs, as outlined below, as a specific implementation according to Cookson’s interpretation.

Summary measure for policy

Since public health interventions may impact other well-being components besides health and since social welfare policy and reform (education, labour market, social insurance, etc.) may also affect lifetime health, it seems meaningful to establish a summary measure of capabilities. This requires the acceptance that one capability (e.g., income) can be traded for another capability (e.g., health) [17] and that agreement can be reached on the relative values of the included capabilities [12]. For a specific context, it is possible to distinguish different kinds of capabilities based on the extent to which a society ought to make them available to an individual. In democratic high-income countries such as Sweden, one category comprises capabilities that everybody has an undisputed right to have access to, such as political resources or a minimal threshold of education through basic schooling. For other capabilities, there may be less consensus that everybody should have them to the same extent, for example, the capability to be wealthy enough to buy property or to have an occupation that one is always completely happy with. Hence, important questions to ask are the following: (a) Which capabilities are sensitive to public polices? (b) Which capabilities can best explain differences in quality of life? An example relevant to the Swedish context may be that the capabilities of beauty and love are important but not easy targets for public decision making, whereas access to clean water and air does not discriminate sufficiently since all inhabitants have these capabilities to a reasonable extent.

Another acknowledgment is that an applied conceptualisation of the capability approach should take opportunity into consideration as well as achievement. According to Sen, capability is the freedom to achieve valuable functions, which is often illustrated by the difference between voluntary fasting and involuntary starving [18]. A corresponding example from the context of a high-income country could be freely chosen retirement versus involuntary unemployment at the age of 60 years. Nussbaum’s point here is that policy should not focus on what people choose to do but their capability to function well if they choose to do something [19]. In empirical analysis, the assumption is often that the functions an individual possesses provide fair understanding of the capabilities that he/she has had access to [20], i.e., a rational person chooses the most attractive functions available in his or her set of capabilities.

Other approaches and our proposal

Based on the explicit assumption that QALYs may be too restricted for health and social care, Al-Janabi et al. [21] developed a descriptive capability-based system labelled ICECAP-A (ICEpop CAPability measure for Adults), together with weights linked to key capabilities [22]. According to Mitchell et al. [23], an additional approach in economic evaluations could be to consider shortfalls from ‘sufficient capability’. Another example for operationalisation of the capability approach for public health is the OCAP-18 measure by Lorgelly et al. [24].

Our contribution, CALYs, is an outcome measure, for monitoring trends and distributions, as well as evaluating public health and social interventions. CALYs will be calculated based on capability weights for different quality-of-life states, from 0 (worst) to 1 (best). For example, a state that represents the quality of life for a given capability set may have a weight of 0.7 attached, resulting in 0.7 CALYs for a person-year, i.e., the same concept as in QALYs. Whereas QALYs are appropriate in situations where the main interest are health benefits, CALYs aim to be used in situations where the goal is to measure changes in individuals’ general capabilities.

Key aspects of CALYs are that we rely on a deductive, rather paternalistic approach, by mainly trusting so-called ‘fair-minded people’ to select relevant capabilities [25]; that we consider a trade-off between equity and efficiency according to the fair innings argument by Williams (i.e., considering good before perfect years) [26]; and that we rely on revealed public preferences for establishing the threshold value for a CALY [27]. We envision a simple structure for CALY states with a limited number of capability dimensions and levels of achievement, similar to the EQ-5D-3L construction [28], for the purpose of facilitating both the further development and application of CALYs. The definite configurations of dimensions and levels still needs to be determined.

Collapsing different capability levels into a single index may conflict with Sen’s suggested capability approach that rejects complete orderings [12]. However, the QALY concept has demonstrated the usability of a simple quality weight for policy making where the advantages of this abstraction enabled efficient applications of extra-welfarist concepts. The preference-based process of eliciting QALY weights also is a pragmatic democratic approach to average the value judgement of representative population samples.

The development of the CALY measure necessitates to develop a procedure to decide which capability dimensions should be included. To our knowledge, no previous work specific to the Swedish context exists that has attempted to assess a relevant ranking of capabilities based on survey data.

In this study, the aim was to examine the possibility of ranking capabilities by their importance for quality of life and to tentatively indicate a selection of most relevant capabilities based on various metrics among Swedish respondents. In relation to the overall project, the purpose was to collect information for the selection of dimensions for the CALY measure. We found that ranking capabilities is feasible and that health, social relations, and financial situation were ranked highest by a non-representative sample of researchers and doctoral students in health-related disciplines at five Swedish universities.

Materials and methods

List of suggested capabilities

The Swedish government commissioned an investigation [29] to review, analyse, and propose measures for quality of life. The appointed investigator and experts conducted a literature review. The investigation proposed a list of 10 freedoms of action and achievements to be particularly important for people’s quality of life, based on previous lists by Johansson [30], the Report by the Commission on the Measurement of Economic Performance and Social Progress by Stiglitz, Sen, and Fitoussi [31], and the OECD [32]. We considered these as representing a relevant list of capabilities for our purpose, and we added a short interpretation for each in relation to what it means to live well in present-day Sweden, based on their description in the government’s investigation [29]:

Time: experiencing a balance between necessary activities (work, other duties) and voluntary activities (social contacts, physical activity, entertainment, hobbies, etc.).

Financial situation: having monetary means (salary, other income, savings) that permit an enjoyable living standard.

Health: having a health status (mental and physical) that does not limit the possibility of working or engaging in other wanted activities.

Political resources: having the opportunity to form an opinion on minor and major issues and being able to present them while being treated with respect (polling stations, associations, authorities, media, etc.).

Knowledge: having the education and experience required to work with or engage in interesting issues and purposeful activities.

Living environment: being in an enjoyable and practical context (neighbours, buildings, parks/nature, transportation, stores, etc.).

Occupation: having satisfying work or other engagements (studies, internships, household work, care of relatives, etc.).

Social relations: having access to close relationships (family, friends, acquaintances) that contribute to pleasure and development and to persons that offer advice and support when needed.

Security: not feeling afraid of being afflicted by burglary, vandalism, or various kinds of threats of violence, either at home or in other places.

Housing: having affordable and stable housing that is appreciated in terms of functionality, appearance, and location.

Survey respondents

Potential survey respondents were a convenience sample of Swedish-speaking researchers and doctoral students in the disciplines of public health, global health, epidemiology, medicine, women´s and children´s health, and health care at five Swedish universities. In agreement with Sen’s proposal for a context-sensitive adaptation of the capability approach, the survey language was Swedish.

The number of potential respondents was about 830 in total, of which, approximately 100 were from the Department of Public Health Sciences, Karolinska Institutet; 440 were from the Medical Faculty at Lund University; 40 were from the Unit of Epidemiology and Global Health at Umeå University; 180 were from the Department of Women’s and Children’s Health and the Department of Public Health and Care Science at Uppsala University; and 70 were from the University Health Care Research Center at Region Örebro County. The number of respondents was 171, although 4 of them did not explicitly indicate consent to participate. Hence, the sample size was 167, making up an estimated response rate of 20% (167/830).

Procedure and questionnaire

An application for complete ethical review was sent to the Stockholm Board for Ethical Clearance (EPN). An advisory statement concluded that EPN had no ethical objections to the study (Protocol 2016/4). Informed consent to participate was obtained from all individual respondents included in the study, and the study was conducted according to the principles expressed in the Declaration of Helsinki.

The invitation to participate in the web-based survey was sent by email (28 May, 2016), with information about the aim, invited participants, ethical statement, contact information, and deadline (15 June, 2016). The survey was accessible at once. The attached documents consisted of an informational letter (background, aim, task, estimated time taken, risks and benefits, handling of data, presentation of results, and voluntariness) and a summarised research plan (the overall project and the study). This was followed by a reminder (10 June, 2016).

First, the respondents were asked to give informed consent to participate in the survey by ticking a checkbox. The respondents then ranked the list of 10 capabilities from 1 (the most important capability) to 10 (the least important capability). The instructions were that any rank (1, 2, 3, …, 10) could be used only once to arrive at a unique ordering. The intent of using a ranking task was to promote trade-offs between the capabilities and avoid participants indicating all capabilities as important. Finally, the respondents were asked to enter gender (male, female, other, empty), age (<30 years, 30–39 years, 40–49 years, 50–59 years, 60+ years, empty), research field (free text), and potential comments (free text). The original Swedish and translated English questions from the survey are provided in S1 Questionnaire. For later analysis, we categorized the free-text research field answers into medicine, public health, social science, and other. We pre-tested the survey informally in our networks outside academia.

Sen (1998) has argued that health is probably the best indicator of people’s well-being if one has to select only one, and the respondents were researchers in health-related disciplines. This led us to assume that some respondents may have fulfilled the task correctly but with an inverse ranking from 10 (the most important capability) to 1 (the least important capability) if they assigned health, together with social relations or financial situation, a rank greater than 5. To assess the impact of potentially inverse rankings, a sensitivity analysis was conducted without responses where health was assigned a greater than 5.

Statistical analysis

We calculated means and medians overall and stratified by gender, research field, and age group. We also calculated the cumulative number of times a capability was ranked 1 to 2, 3, 4, or 5. We used bootstrapping with 10,000 resamples to calculate confidence intervals for means and medians because the underlying rank data may not have been normally distributed. Furthermore, we dissected the rankings into pairwise comparisons of two capabilities and examined for each pair the number of times one capability was ranked ahead of the respective other, hereafter termed the win count balance. For example, a win count balance of 5 for A over B means that A was ranked 5 times ahead of B. We used the win count balance to look for systematic patterns among the combinations. We used R 3.6 for all analyses [33].

Results

Among the 167 respondents who consented, 112 respondents (67%) completed the task correctly (i.e., assigned 10 unique ranks to the 10 capabilities), whereas 55 respondents (33%) completed the task incorrectly (i.e., incomplete rankings). Three incorrect responses (2%) contained 9 unique ranks, which made it possible to impute the missing rank. The main results presented below are based on the correct responses plus the 3 imputed responses (n = 115).

Study participants were mostly female (74 women compared with 39 men and 2 unanswered) and came from health-related fields (29 from medicine and 40 from public health compared with 21 from social science, 9 other 16 unanswered). All participants except for 3 were older than 30 years old. The lowest age category was excluded from stratified analysis because of the low strata size. shows the characteristics of participants.

shows the distribution of ranks per capability dimension. Health was most often ranked first, social relations was most often ranked second, and financial situation was most often ranked fifth. Distributions were less accentuated and more broadly distributed for knowledge, security, time, political resources, occupation, housing, and environment. Political resources, housing, and environment had 10, 9, and 8 as the most frequently assigned ranks.

Distribution of ranks per dimension.

Distribution of ranks for all capability dimensions, with the number of rankings above the bars. Teal indicates the most frequently chosen rank, the dashed grey line is the mean rank, and the dashed black rectangle is the median rank. Subheadings denote the proportion of times a dimension was ranked 1–5 out of the 115 answers.

Each cell in shows the number of times the capability in the row was ranked ahead of (positive values) or behind (negative values) than the capability in the column (win count balance). We discovered a pattern where the binary relation that consists of all combinations of capabilities with positive win count balances forms a strict total order for a set of five capabilities [34]: negative row values before and positive row values after the 0 diagonal values imply health > social relations > financial situation> knowledge > occupation, although sometimes by very small margins (e.g., occupation vs. time and knowledge vs. security). In other words, for the five capabilities, for any capability A and another capability B, if A was ranked ahead of B more often and if B was ranked ahead of a third capability C more often, then A was also ranked ahead of C more often. The other five capabilities (time, security, political resources, housing, living environment) were dominated by the above five capabilities, but they did not reveal similar patterns.

also indicates the cumulative count of a capability having been ranked 1 to 5. By this metric, health (87) was deemed most important, followed by social relations (75) and financial situation (67), whereas living environment was ranked least important (40). The counts for knowledge, security, time, political resources, occupation, and housing were clustered together (48 to 56).

depicts the overall median ranks by gender (women and men), research field (public health, medicine, social sciences, and other), and age group. Overall, the capability of health was top-ranked (median rank 2), followed by social relations (4) and financial situation (5), whereas housing (7) and living environment (7) were bottom-ranked. The 95% confidence intervals (CIs) for the medians of health and social relations did not overlap, whereas the CIs for the other medians all included rank 5, with an exception for living environment, with a 95% CI of 6–7.

When stratifying by gender, research field, and age group, health and social relations had the top 2 median ranks, except for the research field ‘other‘, where social relations was positioned behind financial situation and occupation. Housing and living environment consistently had a median rank of 6 to 8 in the different strata, apart from rank 5 for housing for the age group 30–39 years. Median ranks across research fields were mostly similar. Across age groups, the mean rank of social relations decreased with increasing age, from 5 for 30–39 years to 2 for 60+ years. The median rank of time for age groups 30–39 years and 40–49 years contrasted with the median rank of age groups 50–59 years and 60+ years (5 and 4 vs. 7.5 and 7, respectively).

depicts the bootstrapped overall mean ranks for the same strata as for the median ranks (). Health and social relations were ranked highest on average (3.43 and 4.48, respectively), and housing and living environment were ranked lowest (6.21 and 6.35, respectively). Mean ranks differed relatively little for the 8 bottom-ranked capabilities and were clustered between 5.37 and 6.35. Health and social relations were consistently among the top 3 mean ranks across all strata. The mean rank of financial situation was the third highest for men, whereas the third-highest mean rank for women was knowledge. The third-highest mean rank differed considerably across age groups and research field; for example, time was the third highest for age groups 30–39 years and 40–49 years, but it was the second lowest for the age group of 60+.

Sensitivity analysis

Twenty-eight respondents ranked health greater than 5. Of these 28 respondents, 25 also ranked social relations or financial situation greater than 5, together with health. Because health, social relations and financial situation where otherwise ranked 1 to 3 by all metrics; this may indicate reverse rankings. For the sensitivity analysis, in which these 28 potential reverse rankings according to the health criterion were excluded from the 115 respondents in the main analysis, the rankings of importance varied little. The number of times a capability was ranked 1 to 5 resulted in the same first 5 positions (health, social relations, financial situation, knowledge, security). Similarly, the total order relation on the win count balance with health > social relations > financial situation > knowledge > occupation did not change. The order implied by the mean ranks also largely remained the same; only time and security (position 6 and 7 with all data) switched. The order implied by the median ranks did not change for the top 3 positions, but time, political resources, and security had a median rank of 7 and thus position 5, leaving knowledge and occupation alone at position 4 with a median rank of 6. The most frequent rank only changed for political resources to position 10.

Discussion

Main findings

This study represents a step towards CALYs, a novel outcome measure for public health and social welfare. Most of the respondents who consented managed to rank the proposed set of capabilities. This indicates that it is possible to discriminate between these capabilities in terms of their importance for quality of life. The results suggest that participants deemed health to be most important, followed by social relations and financial situation. Knowledge, occupation, time, security, political resources, housing, and living environment were ranked lower, and the exact order depends on the metric used to synthesise the individual rankings.

Endorsing the capabilities

Our gross list of capabilities consisted of 10 indicators of quality of life, considered to be theoretically sound, empirically valid, policy relevant, and measurable by survey or registry data [29]. To test the validity in terms of representing capabilities, one may pragmatically compare the utilised indicators with the 10 basic capabilities proposed by Nussbaum [19]. For instance, ‘Bodily Health’ and ‘Bodily Integrity’ connect to health and security; ‘Senses, Imagination, and Thought’ connects to knowledge and political resources; ‘Other species’ connects to the living environment; ‘Play’ connects to time, social relations, and occupation; and ‘Control over One’s Environment’ connects to housing and financial situation. All in all, we propose that the capabilities considered be endorsed in the sense of being covered by Nussbaum’s classical list.

Ranking of importance and comparison with other studies

Constructing a ranking of importance is challenging. Overall, health is clearly placed first in terms of frequency, mean, median, and win count balance metrics, followed by social relations and financial situation. Differences between positions from 3 to 10 were less pronounced. Placing occupation and knowledge as two of the 5 most important capabilities was supported by the total order relation formed by the win count balance, the mean, the median, and the most frequent metrics. The number of times a capability was ranked 1 to 5, however, did not result in occupation being included in the top five but instead favouring security. The mean, median, most frequent rank, or number of times being ranked from 1 to 5 offered little insight into the fifth most important capability due to the small differences from the subsequent positions. Occupation, time, security, political resources, and housing (but not living environment) are all contenders.

Beyond the limited size and biased nature of the sample, none of the different metrics used here offer a definite answer to the question of importance ranking; they all have individual advantages and disadvantages. The median is appropriate for ordinal data and takes into account the whole distribution of ranks; the most frequent rank reflects the opinion of the largest group, and the total order based on the win count balance relies only on comparisons of two alternatives. However, all of these lack discriminative power or they can be ambiguous. The mean rank may be less suited to rank data due to its ordinal nature, but it offers more discriminative power since mean ranks are likely to differ, even if the underlying distributions are similar. Counting the rankings between 1 and 5 offers better discrimination, but it only reflects whether a capability ranks in the top 5, and it fails to take into account further distributional differences in each of the two halves of the ranking scale.

A high proportion of participants stated in the free-text reflections that they perceived the ranking task as difficult. Assuming higher variance due to these difficulties, these comments support the result of the empirical analysis, in which only health, social relations, and, to some extent, financial situation were clearly positioned ahead of the other capabilities. Although this qualitative aspect lies beyond our quantitatively focused analysis, such input is valuable for informing the selection process and for refining the survey design to facilitate the ranking as much as possible.

The ranking may be compared with studies by Anand et al. [35] and Al-Janabi et al. [21]. Anand et al. tested the effects of basic capabilities (28 indicators) on well-being (satisfaction with life overall, health, home, income, partner, job, social life, leisure, etc.), controlled for partner and job (having, not having) and personality traits (‘always look on the bright side’). The challenge of selecting capabilities, and not simply functionings, was guided by the following two types of questions: first, those that ask about general capabilities, such as health and education, which have implications for what we can do in other areas of life; and, second, those that ask about particular capabilities, such as ‘Would you like to be able to pay for a week's annual holiday away from home, but must do without because you cannot afford it?’ The authors found a strong argument for considering the capabilities of good health and sexual freedom, social interaction and self-worth, and happiness and amusement. When developing the ICECAP measure, Al-Janabi et al. [21] found particular support for the over-arching capability attributes of feeling settled and secure; love, friendship, and support; being independent; achievement and progress; and enjoyment and pleasure. The supplementary population tariff shows that ‘attachment’ and ‘stability’ accounted for around 22% of the total value, whereas ‘autonomy,’ ‘achievement,’ and ‘enjoyment’ accounted for about 18% [22].

Hence, even though our study has limitations, its findings have broader support. To endorse the high rankings of financial situation and knowledge, which were not highly valued in the studies by Anand et al. [35] and Al-Janabi et al. [21, 22], one may refer to the well-known ecological interpretation of the capability approach, i.e., the human development index (HDI), considering gross national product, life expectancy, and literacy [36].

Limitations

This study was not designed to assess a definite representative ranking order of important capabilities in the Swedish context and should not be used as such. The study participants were not representative of the Swedish population and consisted of researchers in health-related disciplines. Hence, they are likely biased towards valuing health, but also other capabilities such as knowledge and social relations as determinants of health, as particularly important.

Deciding on how many capabilities should be included in the CALY measure based on ranking data may be arbitrary because the ranking task does not directly yield information about the relative strengths of the different capabilities. Additionally, there are limitations regarding the aim of examining the possibility of ranking capabilities per se. First, we do not know whether the low response rate was due to explicitly refusing to rank capabilities or to reasons such as lack of time and interest. Second, we do not know the characteristics of the respondents (researchers and doctoral students) in terms of their ranking capacity. Third, the web-based survey had technical limitations that need revision, such as allowing for ranking two capabilities with the same number. Similarly, the occurrence of suspected inverse rankings is an indicator that the instructions and visual design of the survey need improvement. Fourth, we did not a priori calculate a required sample size or validate the questionnaire.

Future research

The limitations of the study confirm our intention to select capabilities based on an approach that, in extra-welfarist fashion, does not only empirically consider individual preferences, namely inviting ‘fair-minded people’ [25] to discuss the most relevant capabilities for the Swedish context in a participatory Delphi process [37]. We have also explored the calculation of CALY weights in a web-based survey among 2,000 Swedish residents [38]. The study explored discrete choice and time trade-off questions [39] to calculate weights, and anchored them on a 0 (worst) to 1 (best) scale. Among health, social relations, financial situation, knowledge and occupation, the highest-valued capability dimensions in this study were health and social relations. These survey results, together with the results presented here, were used to inform the Delphi process (manuscript in preparation). After the selection of capabilities is finished, we will continue the development of the CALY measure by finalizing the instrument, performing a valuation study for eliciting CALY weights, and finally applying the measure in economic evaluations.

Conclusions

We conclude that, given clear instructions and alternatives, it is possible to generate a ranking of capabilities by their importance to quality of life. The analysis of the ranking responses shows that health, social relations, financial situation, and potentially knowledge may be relevant capabilities for the Swedish context and for inclusion in the CALY measure. This result informs the continued development of the CALY measure.

Survey questions in Swedish and translated to English.

(DOCX)

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9 Jul 2020

PONE-D-20-06320

Towards capability-adjusted life years in public health and social welfare: Results from a Swedish survey on ranking capabilities

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Reviewer #3: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you or the opportunity to review the paper, which aims to rank the importance of capabilities and to indicate relevant capabilities for the Swedish context. The paper is part of a larger project that aims to develop a measure for quality of life for policy making based on the CALYs framework. I think this is an important area of research but I believe the authors need to provide some further clarification and justification points for their chosen approaches, which are not only of importance for the current paper but the project overall. I have two major concerns related to the concept of CALYs as well as the methodology applied in this study.

Regarding the CALY concept, the authors criticize the QALY framework because it is limited to health. However, this is only partly correct. Since the QALY framework is based on the extra-welfarism approach, it can include also non-health benefits (see discussion by Brouwer et al. 2008). The problems is the operationalisation of the current QALY framework, where existing preference-based measure have a strong focus on health. However, this is not a limitation of the QALY framework but rather an issue with existing measures. Indeed, the authors suggest to develop a new measure that consist of 5 capability dimensions and 3 levels and will be valued using DCE and TTO, similar to the EQ-5D, which rather sounds that the authors propose a new preference-based measure, which could easily be implemented into the QALY framework. Secondly, the authors propose the collapsing of multidimensional capabilities information into a single index score using preference-based valuation techniques, which is in tension with Sen’s capability approach but not discussed by the authors. I guess these are comments related to the project overall but also relevant to understand the current paper.

My second major concern relates to the methods applied in this study. Firstly, it is generally known in the capability literature that the selection of capabilities needs to be context specific, and derived from a participatory approach. The authors state that the 10 capabilities were based on a review but it sounds like no interviews with members of the Swedish population have been undertaken. Secondly, the ranking exercise was conducted with researchers and doctoral students in health-related disciplines rather than member of the general population who may hold very different views. Finally, the authors conclude that the ranking results show that it is possible to discriminate between capabilities but fail to acknowledge the limitations of the ranking exercise. Previous literature discussed that ranking exercises do not involve trade-offs and, as such, respondents tend to ignore relative importance and say that everything is important, giving rise to ceiling effects.

Minor comments:

Introduction:

• On page 3, line 55, the authors mention valuable aspects that are currently omitted but do not discuss what these aspects are. Could the authors elaborate on that further?

• A further elaboration on QALYs and how they are derived is needed in the introduction.

• Line 76: could the authors discuss how Cookson’s interpretation of ‘capability QALYs’ is similar or differs to CALYs?

• The rationale for this study was not clear and how it will contribute to the overall project. Suggest re-phrasing the aims of this study in a more clear way.

Methods:

• Why did the authors choose researchers and doctoral students in health-related disciplines rather than member of the general population who may hold very different views?

• Why did the authors decide to use a ranking exercise over and above other techniques?

• The exclusion of participants due to reverse ranking of importance according to health is not clear and not enough justified. I think it is legitimate that some people may prefer other aspects more than health.

Discussion:

• The authors conclude that health was found to be the most important capability. However, I wonder to what extent this is driven by the exclusion of participants based on reverse ranking of importance according to health?

• It is not clear how the results of this study will be used. What is the contribution of this paper to the overall project, especially considering the fact that a valuation study (using DCE and TTO) will be used in future.

Reviewer #2: The study entitled “Towards capability-adjusted life years in public health and social welfare: Results from a Swedish survey on ranking capabilities” is relevant and provides an interesting concept to the reader. It addresses a noteworthy topic of capability-adjusted life years for supporting public health policies. Please find enclosed my comments.

Abstract:

The abstract reads fine, However, the authors mentioned that “overall purpose is to develop a measure for quality of life for policy making based on the capability approach by Amartya Sen”. The reader could be confused that the authors have developed the measure. If the authors would like to put developing the measure as their overall goal, they should at least mention the steps for doing so and the steps needed until they reach this purpose, however, that was out of the scope of this paper. I recommend to re-formulate this section, and to be more focused and clearer, e.g. the purpose is to provide the initial steps/evidence for developing a measure for quality of life for policy making based on the capability approach by Amartya Sen.

Introduction:

Please highlight the gap in literature and why this study is needed before the aim of the study by the end of introduction.

The Author could better tackle the rational of the study with using ranking to develop the measure, in other words, why ranking is important step for developing a measure for quality of life for policy making based on the capability approach.

In lines 55-56, the authors mentioned “Current approaches may omit valuable aspects and impacts and may fail to consider equity goals.” Please add the relevant references and clarify what are the current approaches accordingly.

Although the overall purpose was to contribute in developing a measure for quality of life, the authors didn´t have enough background about QoL and its main domains (e.g. according to the WHO) as well as and its measures. Also, QALYs and how it is linked with the capability approach. It is also important to add evidence about the use and how comparable or different CALYs and QALYs, that will clarify and strengthen the rational of the study. The authors have only pointed out very briefly about EQ-5D-3L.

Lines 119-120 “We envision a structure for CALY states that consists of 5 capability dimensions and 3 levels of achievement, totalling 243 possible states”. Its not clear how the 243 based on the 5 capabilities and 3 levels was reached. Please clarify.

From line 128 to 131 “ We found that ranking capabilities is feasible and that health, social relations, and financial situation were ranked highest by a non representative sample of researchers and doctoral students in health-related disciplines at five Swedish universities”, this paragraph should not be in the introduction, it is a finding so I recommend to move it to the discussion or results sections.

Methods:

Line 136, the author mentioned about piloting purposes, did the author do a pilot study or what did they mean in this section? a Pilot study is performed in a very small scale to be able to develop and improve the actual study on a full scale. Please clarify.

Regarding the study population what was the rational behind selecting the sample from health-related disciplines, and what does that means for the results?, because it is very important to reflect all views of capabilities in this ranking given that health related population might rank capabilities differently from the general population. Would the authors expect different results from different populations characteristics?

Please provide information about sampling technique (e.g. convenience, random,..). Did the authors calculate a sample size?

Statistical analysis: Line 203, “We calculated means and medians per strata” which strata?, in order to be clear, the authors can mention here the stratification done by gender, research field, and age group.

Results:

The number 115 was the sum of 112 who fulfilled the task correctly + 3 imputed responses. In this regard, line 215, it´s not clear where were the 28 respondents (17%) excluded from, and on which group did the authors perform their sensitivity analysis?

What is the rationale behind presenting both mean and median rank? Shouldn´t that be determined according to the data distribution and then choosing mean or median whichever would be meaningful for the data, what do the authors think about that?

In Table 1, some items are hidden visually within the table e.g. Political rights, please adjust.

In Table 1, what does it mean for the results that the ranked 1 to 5 column showing occupation less than time, security, and political rights, yet for the win count balance occupation was higher eventually?

Discussion:

Implication of this study and how it provides evidence and a step forward for developing CALYs needs to be emphasized.

How the study with its ranking strategy would contribute to the ultimate goal of developing a measure for quality of life based on capability approach, and what are the future needed steps?

Why the authors have focused on the top ranked 5 and not 6 or7?

Limitations:

The limitations mentioned by the authors were clear, however, lines from 388-392, didn´t seem like they belong in the limitations, e.g. “an info about exploring the calculation of CALY weights in a web-based survey among 2,000 Swedish residents”, this important statement should be discussed in the discussion instead including how that impact this study.

Overall, the study is well written and provide resources for the most important needed domains of capabilities, However, it needs to be very clear within the paper how this step contributes to the overall development of CALYs.

Reviewer #3: This paper reports results from a ranking exercise, undertaken by academics working in health related disciplines at five universities across Sweden. 10 broad reaching attributes (interpreted as capabilities) are identified from a Government review, for inclusion within the ranking exercise. There is an aspiration to eventually develop a five dimension measure, with a scoring system, which can be used to calculate capability-adjusted life years.

Whilst I support the rationale for developing such a measure, and whilst I agree that a case could be made for narrowing down the initial list of 10 capabilities to a manageable number through such a ranking exercise (with expert participants), I felt that there were a number of significant issues with the framing, methods, interpretation and contribution of the manuscript as it currently stands. Given the significance of these issues, I will not pick up on many specific points relating to presentation, but in relation to presentation, I will very briefly add that the message was unclear on page 4 (lines 85 to 89) and on page 5 (lines 115 to 118), and these sections will need to be rephrased to ensure clarity when resubmitting any future draft.

Framing and motivation:

- I felt that more information is needed about how the list of 10 capabilities were initially identified. I appreciate that this work was completed by external agencies and that a reference is given, but I had no idea why or how the 10 capabilities were identified or indeed how valid the process was. These 10 capabilities are the starting point/foundation for everything that the research team report here. Were they interpreted as capabilities by the agency that undertook work to identify them? On what basis did the research team come up with the short descriptions for the 10 attributes?

- What was the justification for (exclusively) recruiting health-related academics to complete the weighting task? Why not health/public health experts working in public sector/Government/local authority agencies? Why were health academics deemed to have an exclusively relevant perspective?

- Linked to the previous point, the researchers appear to have an a priori assumption that health should (perhaps even must) appear in the top 5, but little justification is given for this. I fear this a priori belief biases their perspective, with the suggestion that those academics not ranking health highly misinterpreted the scale. If there is a starting position that health should be in the top 5, why not simply include it

- why was it decided that 5 attributes were needed? This seems entirely arbitrary. The problem with this methodology is that it gives you no information on the relative VALUE of attributes and no information to decide whether 4 or 5 or 6 attributes stand out as being really important; so it relies on an arbitrary a priori decision.

Methods:

- It is not clear what background academics were given as to the nature of the task and why the ranking exercise was being undertaken. What perspective were academics asked to adopt (personal or societal)? Were they told what the short list of attributes would be used for? Were they expected to consider the policy agenda or things such as the current financial and environmental climate?

- This is a fundamentally basic task (OK, it requires people to make complex value judgements, but technically, a ranking task should be straightforward for an academic sample) and yet a third of respondents 'got it wrong'. I find this worrying and it needs further consideration and discussion.

Results:

- For such a simple task, the analysis is rather complicated! Numerous means of ranking attributes are reported but no indication is given as to which is most useful or most valid. It is seemingly entirely exploratory, but then there is seemingly also no conclusion / no recommendation from the work?

Discussion / conclusion:

- I am at a bit of a loss to see what the take home message of this paper is? The methods appear problematic, there is no clear recommendation of which five attributes should be taken forward to develop into a measure. It appears that other methods and other samples have been used to address the same question, but no indication of whether that gives us a definitive conclusion either. So I cannot see how any of the research results presented actually inform the overall research objective / future aspirations? Indeed the authors seem unsure themselves saying "This result may inform the continued development of the CALY measure".

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Reviewer #1: No

Reviewer #2: Yes: Maisa Omara

Reviewer #3: No

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21 Sep 2020

Dear Reviewers and Editor

We would like to extend our gratitude and appreciation to you and the reviewers for your efforts in reviewing our manuscript and for providing important and helpful comments and suggestions.

We incorporated the majority of the suggestions, and we think that the suggested changes substantially improved the quality of the manuscript. For example, the relation to the overall CALY project and future research is now described much clearer, and we clarified the limitations regarding that the participants have a background as researchers health-related fields.

You find below with point-by-point responses to the individual comments.

Our individual responses are listed below, grouped by reviewer and editor.

Sometimes we refer to other comments using a numbering scheme: E stands for Editor, and R1, R2, or R2 for reviewer 1 – 3. The comment number refers to the number in the left column.

We also provide these comments in a more accessible form as a table in the seperate "Response to reviewers" file.

Editor

____________________________

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at …

Reply: Thank you for pointing out these shortcomings. We changed the filename of figure1.eps to Fig1.eps according to the style requirements. We added the city names to the affiliations. We also adjusted the font size of the headings and the intend of paragraphs to match the style templates.

____________________________

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses.For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Reply: Thank you for highlighting the need for providing the questionnaire. We added supporting information with questionnaire in both Swedish (original language) and English (for documentary purpose).

Where:

Supplementary information S1

____________________________

2 (cont). Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated .

Reply: We added a sentence “We pre-tested the survey informally in our networks outside academia.” Under Procedure and questionnaire in the Methods section. We also added a sentence under Limitations: “Fourth, we did not a priori calculate a required sample size or validate the questionnaire.”

Where:

246-247, 461-462

____________________________

3. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants.Please ensure you have provided sufficient details to replicate the analyses such as:a) the recruitment date range (month and year),

Reply: Thank you for suggesting adding additional information about the recruitment and participant characteristics. We agree that this information is crucial and needs to be presented clearly. The information on date range, recruitment, and survey process is provided under Procedure and questionnaire. To elaborate on the recruitment date range, we added a sentence: “The survey was accessible at once.” under Procedure and questionnaire. We also list the stratification criteria under Statistical analysis.

Where:

231, 257-258

____________________________

3. b) a description of any inclusion/exclusion criteria that were applied to participant recruitment.

Reply: For clarification, we clarified that the study population was “Swedish-speaking” participants under the heading Study population. Beyond language, there were no inclusion/exclusion criteria besides the informed consent to participate.

Where:

208

____________________________

3. c) table of relevant demographic details.

Reply: We added a new table (Table 1) with the number and proportion of participant background characteristics under Results. The numbering of following tables was increased by 1.

Where:

278

____________________________

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.. a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

Reply: We decided to publish a minimal anonymized dataset. Please see the cover letter for a detailed explanation.

Where:

Cover letter

____________________________

b) Uploading the anonymized data set necessary to replicate the study findings.

Reply: See E4 a). We uploaded the data to the Swedish national data service. A DOI has been reserved but is not yet accessible due to pending review. In the meantime, we provide the dataset as part of the submission.

Where:

HYPERLINK "https://doi.org/10.5878/r2nm-zc35" https://doi.org/10.5878/r2nm-zc35

____________________________

____________________________

Reviewer #1

____________________________

1st main. Regarding the CALY concept, the authors criticize the QALY framework because it is limited to health. However, this is only partly correct. Since the QALY framework is based on the extra-welfarism approach, it can include also non-health benefits (see discussion by Brouwer et al. 2008). The problems is the operationalisation of the current QALY framework, where existing preference-based measure have a strong focus on health. However, this is not a limitation of the QALY framework but rather an issue with existing measures. Indeed, the authors suggest to develop a new measure that consist of 5 capability dimensions and 3 levels and will be valued using DCE and TTO, similar to the EQ-5D, which rather sounds that the authors propose a new preference-based measure, which could easily be implemented into the QALY framework.

Reply: Thank you for pointing out this important issue. We agree that this needs to be clarified and our intent was to convey that QALY is of extra-welfarist nature and not limited to health. We added a sentence “Due to the extra-welfarist nature, the QALY concept is in theory not restricted to measuring health benefits but in practice mostly used to measure health consequences“ under the heading Theoretical issues.

Where:

94-95

____________________________

2nd main. Secondly, the authors propose the collapsing of multidimensional capabilities information into a single index score using preference-based valuation techniques, which is in tension with Sen’s capability approach but not discussed by the authors. I guess these are comments related to the project overall but also relevant to understand the current paper.

Reply: Thank you for your comment and helpful suggestion. We agree that the capability approach as outlined by Sen conflicts in this aspect with the proposed CALY measure and that it is crucial to discuss. We discuss this now under Other developments and our proposal

Where:

156-161

____________________________

3rd main. My second major concern relates to the methods applied in this study. Firstly, it is generally known in the capability literature that the selection of capabilities needs to be context specific, and derived from a participatory approach. The authors state that the 10 capabilities were based on a review but it sounds like no interviews with members of the Swedish population have been undertaken.

Reply: Thank you for pointing out this issue. We agree with your concern. The aim was to investigate the ranking of capabilities in a survey. The context specificity is given by using a Swedish example. We have clarified that a participatory Delphi process approach using the results from this ranking study was planned and has now been conducted (manuscript in preparation), under Future research. We also provide more context about the governmental investigation that selected the 10 capabilities under Material and Methods.

Where:

466-473, 175-183

____________________________

4th main. Secondly, the ranking exercise was conducted with researchers and doctoral students in health-related disciplines rather than member of the general population who may hold very different views.

Reply: Thank you for sharing your concern. We acknowledge this limitation. The aim was to investigate the feasibility of ranking and indicate a tentative selection. We clarified the limitation in the Limitations section with a sentence: “The study participants were not representative of the Swedish population and consisted of researchers in health-related disciplines. Hence, they are likely biased towards valuing health, but also other capabilities such as knowledge and social relations as determinants of health, as particularly important. “ We also provide more detail on the professional background under Study population, the first sentence now reads “The study population consisted of Swedish-speaking researchers and doctoral students in the disciplines of public health, global health, epidemiology, medicine, women´s and children´s health, and health care at five Swedish universities.”

Where:

445-450, 208-212

____________________________

5th main. Finally, the authors conclude that the ranking results show that it is possible to discriminate between capabilities but fail to acknowledge the limitations of the ranking exercise. Previous literature discussed that ranking exercises do not involve trade-offs and, as such, respondents tend to ignore relative importance and say that everything is important, giving rise to ceiling effects.

Reply: We agree that it is important to avoid ceiling effects and thank you for considering this important issue. To promote trade-offs, we chose to use a ranking task where participants were instructed to assign unique ranks from 1 to 10 to the dimensions, as opposed to for example rating where respondents would assign values from 1 (least) to 10 (most important) to rate their importance. This could result in valuing all dimensions as 10. We clarified this property under the Methods heading by inserting the sentence “The intent of using a ranking task was to promote trade-offs between the capabilities and avoid participants indicating all capabilities as important.”

Where:

239-241

____________________________

Introduction

____________________________

1st minor. On page 3, line 55, the authors mention valuable aspects that are currently omitted but do not discuss what these aspects are. Could the authors elaborate on that further? 1st minor

Reply: Thank you for your suggestion. We reworded and extended the on the wording to clarify the context.

Where:

64-69

____________________________

2nd minor. A further elaboration on QALYs and how they are derived is needed in the introduction.

Reply: Thank you for your suggestion, we agree and included a description of QALYS and how QALY weights are derived.

Where:

84-92

____________________________

3rd minor. could the authors discuss how Cookson’s interpretation of ‘capability QALYs’ is similar or differs to CALYs?

Reply: Thank you for your comment. We changed and expanded the wording to clarify: “Due to the extra-welfarist nature, the QALY concept is in theory not restricted to measuring health benefits, but in practice is used mostly to evaluate health consequences. Cookson [16] suggested a ‘capability QALY’ interpretation of QALYs as a “cardinal index of an individual’s capability set”. We see CALYs, as outlined below, as a specific implementation according to Cookson’s interpretation.”

Where:

94-98

____________________________

4th minor. The rationale for this study was not clear and how it will contribute to the overall project. Suggest re-phrasing the aims of this study in a more clear way.

Reply: We inserted a sentence after the aim: “In relation to the overall project, the purpose was to collect information for the selection of dimensions for the CALY measure.” See also 9th minor.

Where:

168-170

____________________________

Methods

____________________________

5th minor. Why did the authors choose researchers and doctoral students in health-related disciplines rather than member of the general population who may hold very different views?

Reply: Thank you for your comment, please see R1, 4th main.

____________________________

6th minor. Why did the authors decide to use a ranking exercise over and above other techniques?

Reply: Thank you for your comment, please see R1, 5th main.

____________________________

7th minor. The exclusion of participants due to reverse ranking of importance according to health is not clear and not enough justified. I think it is legitimate that some people may prefer other aspects more than health.

Reply: Thank you for your suggestion. We further clarified how the sensitivity analysis was done under Methods and Results->Sensitivity analysis. See also R2, 14, and R3, 3.

Where:

248-254, 354-368

____________________________

Discussion

____________________________

8th minor. The authors conclude that health was found to be the most important capability. However, I wonder to what extent this is driven by the exclusion of participants based on reverse ranking of importance according to health?

Reply: Thank you for your inquiry. The exclusion based on suspected reverse rankings was only done for the sensitivity analysis. The main results, which the conclusions are based on, did not exclude participants. Furthermore, the ranking of dimensions was similar in both the main and the sensitivity analysis in all the metrics. See also R1, 7th minor.

____________________________

9th minor. It is not clear how the results of this study will be used. What is the contribution of this paper to the overall project, especially considering the fact that a valuation study (using DCE and TTO) will be used in future.

Reply: Thank you for highlighting this shortcoming. We clarified the next steps of the development in the section Future research, specifically how the results were used to conduct a Delphi process. We further deleted “may” from the concluding sentence which now reads: “This result informs the continued development of the CALY measure.” Please also see R1, 4th minor.

Where:

481, 472-476

____________________________

____________________________

Reviewer #2

____________________________

Abstract

____________________________

1. The abstract reads fine, However, the authors mentioned that “overall purpose is to develop a measure for quality of life for policy making based on the capability approach by Amartya Sen”. The reader could be confused that the authors have developed the measure. If the authors would like to put developing the measure as their overall goal, they should at least mention the steps for doing so and the steps needed until they reach this purpose, however, that was out of the scope of this paper. I recommend to re-formulate this section, and to be more focused and clearer, e.g. the purpose is to provide the initial steps/evidence for developing a measure for quality of life for policy making based on the capability approach by Amartya Sen.

Reply: Thank you for this important observation and helpful suggestions. We agree that it is confusing. We reworded the abstract introduction to “In this study, the aim was to rank the importance of capabilities and to indicate relevant capabilities for the Swedish context to inform the development of capability-adjusted life years (CALYs), a quality of life measure for policy making based on the capability approach by Amartya Sen.” See also R1, 9th minor

Where:

29-32

____________________________

Introduction

____________________________

2. Please highlight the gap in literature and why this study is needed before the aim of the study by the end of introduction.

Reply: Thank you for your suggestion. We inserted “To our knowledge, no previous work specific to the Swedish context exists that has attempted to assess a relevant selection of capabilities based on survey data.” before the aim.

Where:

163-165

____________________________

3. The Author could better tackle the rational of the study with using ranking to develop the measure, in other words, why ranking is important step for developing a measure for quality of life for policy making based on the capability approach.

Reply: We agree that the rationale in relation to the whole project was unclear, thank you for highlighting this. We clarified the rationale behind a ranking task, please see R1, 5th major, as well as the implications for developing the CALY measuring, please see R1, 9th minor.

____________________________

4. In lines 55-56, the authors mentioned “Current approaches may omit valuable aspects and impacts and may fail to consider equity goals.” Please add the relevant references and clarify what are the current approaches accordingly.

Reply: Thank you for your comment, we agree that this is an unclearly formulated. Please see R1, 1st minor

____________________________

5. Although the overall purpose was to contribute in developing a measure for quality of life, the authors didn´t have enough background about QoL and its main domains (e.g. according to the WHO) as well as and its measures.

Reply: Thank you for your suggestion. We agree that it would be informative to have a comprehensive background section on these topics. However, the relevant literature is vast and, in our opinion, goes beyond the scope of this paper. We attempted to find a way of including the WHO definition of quality of life, but we did not succeed in doing so without inadequately prolonging the text. Instead, we suggest to keep to introducing the topic from a (health) economic perspective and the according historical context involving welfarism and extra-welfarism to give the reader an appropriate background.

____________________________

6. Also, QALYs and how it is linked with the capability approach.

Reply: Thank you for your comment. We provide a description of extra-welfarism and capabilities, and how the capability approach may be implemented in a QALY-like manner under the headings Theoretical issues and Other approaches and our proposal. For example, we reiterate Cookson’s suggestion of the capability QALY. We clarified this relation further. Please also see R1, 3rd minor.

Where:

84-98, 139-146

____________________________

7. It is also important to add evidence about the use and how comparable or different CALYs and QALYs, that will clarify and strengthen the rational of the study.

Reply: Thank you for emphasizing the need to clearly differentiate CALY and QALYs. We inserted a sentence “Whereas QALYs are appropriate in situations where the main interest are health benefits, CALYs aim to be used in situations where the goal is to measure changes in individuals’ general capability sets.” Under the heading Other developments and our proposal.

Where:

144-146

____________________________

8. The authors have only pointed out very briefly about EQ-5D-3L.Lines 119-120 “We envision a structure for CALY states that consists of 5 capability dimensions and 3 levels of achievement, totalling 243 possible states”. Its not clear how the 243 based on the 5 capabilities and 3 levels was reached. Please clarify.

Reply: Thank you for y pointing out this shortcoming. We describe EQ-5D now more detailed as an example for QALY, see R1, 2nd minor. The number of different states, or profiles, for an instrument with 5 levels with each 3 dimensions is 243, because 3^5 =243. We altered this section to be clearer, please see R3, 4.

____________________________

9. From line 128 to 131 “ We found that ranking capabilities is feasible and that health, social relations, and financial situation were ranked highest by a non representative sample of researchers and doctoral students in health-related disciplines at five Swedish universities”, this paragraph should not be in the introduction, it is a finding so I recommend to move it to the discussion or results sections.

Reply: Thank you for your comment. We agree that normally statements mentioning results should not be in the introduction. However, we placed this sentence according to the PLOSOne submission guidelines: “Conclude [the introduction] with a brief statement of the overall aim of the work and a comment about whether that aim was achieved” (https://journals.plos.org/plosone/s/submission-guidelines#loc-supporting-information). We asked the editor for clarification regarding this issue.

Where:

Cover letter

____________________________

Methods

____________________________

10. Line 136, the author mentioned about piloting purposes, did the author do a pilot study or what did they mean in this section? a Pilot study is performed in a very small scale to be able to develop and improve the actual study on a full scale. Please clarify.

Reply: Thank you for pointing out this wording. We removed “piloting”. We agree that the wording is misleading here.

Where:

181

____________________________

11. Regarding the study population what was the rational behind selecting the sample from health-related disciplines, and what does that means for the results?, because it is very important to reflect all views of capabilities in this ranking given that health related population might rank capabilities differently from the general population. Would the authors expect different results from different populations characteristics?

Reply: Thank you for comment and valid concerns. Please see see R1, 4th main.

____________________________

12. Please provide information about sampling technique (e.g. convenience, random,...). Did the authors calculate a sample size?

Reply: We clarified under Study population that it was a convenience sample. We did not calculate a sample size requirement. We added an additional sentence under Limitations that reads “Fourth, we did not a priori calculate a required sample size and validate the questionnaire.” to clarify this.

Where:

208-209, 461-462

____________________________

13. Statistical analysis: Line 203, “We calculated means and medians per strata” which strata?, in order to be clear, the authors can mention here the stratification done by gender, research field, and age group.

Reply: Thank you for you proposition, we added the list of strata as you suggested, the sentence reads now: “We calculated means and medians overall and stratified by gender, research field, and age group.”

Where:

257-258

____________________________

Results

____________________________

14. The number 115 was the sum of 112 who fulfilled the task correctly + 3 imputed responses. In this regard, line 215, it´s not clear where were the 28 respondents (17%) excluded from, and on which group did the authors perform their sensitivity analysis?

Reply: Thank you for your comment. We group the sensitivity analysis results under a new subheading under results, Sensitivity analysis. To make it clear where the respondents were excluded from, we used the sentence: “For the sensitivity analysis, in which these 28 potential reverse rankings according to the health criterion were excluded from the 115 respondents in the main analysis, the rankings of importance varied little.”

Where:

358-360

____________________________

15. What is the rationale behind presenting both mean and median rank? Shouldn´t that be determined according to the data distribution and then choosing mean or median whichever would be meaningful for the data, what do the authors think about that?

Reply: Thank you for your comment. We agree that appropriate metrics should be chosen based on distribution characteristics of data. In addition, the nature of the scale, in our case, ordinal ranks, is of importance. We present the distributions of ranks by dimension in Figure 1. The shape of the distribution varies, and skewed distributions may indicate that the mean is not appropriate.However, we primarily chose to report multiple metrics because they each have their advantages and disadvantages, as discussed in the section “Ranking of importance and comparison with other studies”. We clarified this section further. Specifically, means for ordinal data are generally less because they imply that the difference between ranks indicates their relative strength to each other. The median however is the middle of the distributions which is more appropriate for ranks. If occupation ranks 1,1, and 10, the median would be 1 whereas the mean would be 4. Other persons may value occupation the same but other dimensions differently, resulting in the ranks of 1,1, and 4 with mean of 2 and median of 1. The median results in the same rank, but the mean is influenced by how the other dimensions are valued and becomes different, even though both value occupation the same. However, the median rank for two dimensions may be the same even though their distribution varies, for example for 1, 2,2 and 2, 2, 3. In that case, they mean may help to resolve a tie. For a light-read discussion see for example here: https://measuringu.com/mean-ordinal/

____________________________

16. In Table 1, some items are hidden visually within the table e.g. Political rights, please adjust .

Reply: Thank you for pointing this out. We corrected the issue.

Where:

305

____________________________

17. In Table 1, what does it mean for the results that the ranked 1 to 5 column showing occupation less than time, security, and political rights, yet for the win count balance occupation was higher eventually?

Reply: Thank you for your question. It means that occupation was more often ranked ahead of Time, security, political rights, housing, and living environment, but less often in the top five than time, security, and political rights. Consider for example ranks 7, 8; 8, 9; 8, 2 for occupation and time respectively. Occupation wins 2 times against time and loses once, resulting in a win count balance of 2 out of 3 rankings. Yet it is never ranked in the top 5 whereas time is once. The win count balance says something about how many times a dimension was ranked ahead of another one, whereas the top 5 count is more of an overall assessment across all dimensions. We added a sentence “For example, a win count balance of 5 for A over B means that A was ranked 5 times ahead of B.” to better illustrate the concept under the heading Statistical analysis.

Where:

263-265

____________________________

Discussion

____________________________

18. Implication of this study and how it provides evidence and a step forward for developing CALYs needs to be emphasized.How the study with its ranking strategy would contribute to the ultimate goal of developing a measure for quality of life based on capability approach, and what are the future needed steps?

Reply: Thank you for your comment, we agree that the overall picture needs to be clearer. We clarified this under Future research. Please see also R1, 4th minor.

Where:

472-476

____________________________

19. Why the authors have focused on the top ranked 5 and not 6 or7?

Reply: Thank you for highlighting this. Our intent was to explicitly focus on the 5 highest ranked capabilities but rather to arrive at a tentative selection of most relevant capabilities for the Swedish context. Please also see R3, 4.

____________________________

20. The limitations mentioned by the authors were clear, however, lines from 388-392, didn´t seem like they belong in the limitations, e.g. “an info about exploring the calculation of CALY weights in a web-based survey among 2,000 Swedish residents”, this important statement should be discussed in the discussion instead including how that impact this study.

Reply: Thank you for pointing out these unclarities. We agree that the limitations should be clearly distinguishable from future research. We split the Limitations and future research section into two headings, Limitations and Future research to make the distinction clearer and reported the information on the pilot study under the future research section. We clarified the wording, under Future research, because the wording “selecting” is confusing as no selection was done in the study; instead respondents traded-off between different capability states. A direct comparison with the ranking exercise is thus less appropriate and we prefer to keep it in the future research section where this information is strictly related to the planned next steps.

Where:

444, 463, 470-472

____________________________

21. Overall, the study is well written and provide resources for the most important needed domains of capabilities, However, it needs to be very clear within the paper how this step contributes to the overall development of CALYs.

Reply: Thank you very much for your assessment. We agree that the relation the overall project needs to be communicated more clearly. Please see R2, 20. See R1, 4th and 9th minor.

____________________________

____________________________

Reviewer #3

____________________________

0. … in relation to presentation, I will very briefly add that the message was unclear on page 4 (lines 85 to 89) and on page 5 (lines 115 to 118), and these sections will need to be rephrased to ensure clarity when resubmitting any future draft.

Reply: Thank you for pointing out these unclear formulations. We clarified these sections: “In democratic high-income countries such as Sweden, one category comprises capabilities that everybody has an undisputed right to have access to, such as political resources or a minimal threshold of education through basic schooling. For other capabilities, there may be less consensus that everybody should have them to the same extent, for example, the capability to be wealthy enough to buy property or to have an occupation that one is always completely happy with. “ And “For example, a state that represents the quality of life for a given capability set may have a weight of 0.7 attached, resulting in 0.7 CALYs for a person-year, i.e., the same concept as in QALYs.”

Where:

108-113, 140-144

____________________________

Framing and motivation

____________________________

1. I felt that more information is needed about how the list of 10 capabilities were initially identified. I appreciate that this work was completed by external agencies and that a reference is given, but I had no idea why or how the 10 capabilities were identified or indeed how valid the process was. These 10 capabilities are the starting point/foundation for everything that the research team report here. Were they interpreted as capabilities by the agency that undertook work to identify them? On what basis did the research team come up with the short descriptions for the 10 attributes?

Reply: Thank you for pointing out the important necessity to discuss the origin of the 10 capabilities in more detail. We added details the governmental investigation, on the compilation of the list of 10 capabilities and how their descriptions were derived in the manuscript under List of suggested capabilities.

Where:

175-183

____________________________

2. What was the justification for (exclusively) recruiting health-related academics to complete the weighting task? Why not health/public health experts working in public sector/Government/local authority agencies? Why were health academics deemed to have an exclusively relevant perspective?

Reply: Thank you for your comment. We acknowledge the limitation of this convenience sampling and clarified under Limitations. Please also see R1, 4th main.

Where:

446-450

____________________________

3. Linked to the previous point, the researchers appear to have an a priori assumption that health should (perhaps even must) appear in the top 5, but little justification is given for this. I fear this a priori belief biases their perspective, with the suggestion that those academics not ranking health highly misinterpreted the scale. If there is a starting position that health should be in the top 5, why not simply include it

Reply: Thank you for your comment. This is a fair limitation, given we and the respondents come from health-related disciplines ourselves. We did not consider including health from the beginning as we do not want to take a prior decision but aim to conduct a Delphi process with “fair-minded” participants, that relies among other on the findings from this study. Additionally, the respondents may be highly aware of the so-called social determinants of health, i.e. that the other potential capabilities may be essential factors in itself. Please see also R1, 4th main. We did not just suspect potential reverse rankings based on the rank of health, but because often health was ranked 6-10 together with dimensions that were otherwise also commonly ranked 1-5, specifically social relations and financial situation. We added now more details on that and grouped results related to the sensitivity analysis under a new heading Sensitivity analysis, as well as under Procedure and questionnaire in the methods section.

Where:

248-254, 355-360

____________________________

4. why was it decided that 5 attributes were needed? This seems entirely arbitrary. The problem with this methodology is that it gives you no information on the relative VALUE of attributes and no information to decide whether 4 or 5 or 6 attributes stand out as being really important; so it relies on an arbitrary a priori decision.

Reply: Thank you for your comment. We agree that the decision for 5th attributes is arbitrary and that no direct information about relative value of the attributes is provided by the ranking task. However, indirectly the variance among the mid ranks suggests that the dimensions ranked in the mid-tier are of similar value. Health, financial situation, and social relation however are clearly preferred. To clarify, under Other developments and our proposal, we removed the wording “envision a configuration of 5 dimensions with 3 levels”. We inserted the following sentence: “We envision a simple structure for CALY states with a limited number of capability dimensions and levels of achievement, similar to the EQ-5D-3L construction [28], for the purpose of facilitating both the further development and application of CALYs. The definite configurations of dimensions and levels still needs to be determined”. We additionally added a limitation under Limitations to clarify this limitation of the ranking exercise: “Deciding on how many capabilities should be included in the CALY measure based on ranking data may be arbitrary because the ranking task does not directly yield information about the relative strengths of the different capabilities.”

Where:

151-155, 451-453

____________________________

Methods

____________________________

5. It is not clear what background academics were given as to the nature of the task and why the ranking exercise was being undertaken . What perspective were academics asked to adopt (personal or societal )? Were they told what the short list of attributes would be used for? Were they expected to consider the policy agenda or things such as the current financial and environmental climate?

Reply: Thank you for bringing up this point. We describe the survey procedure, including the provided information, under the heading Procedure and questionnaire: “The attached documents consisted of an informational letter (background, aim, task, estimated time taken, risks and benefits, handling of data, presentation of results, and voluntariness) and a summarised research plan (the overall project and the study). This was followed by a reminder (10 June, 2016).”We also added a supporting information file with the exact question phrasings, please see E2.

Where:

Supplementary information S1

____________________________

6. This is a fundamentally basic task (OK, it requires people to make complex value judgements, but technically, a ranking task should be straightforward for an academic sample) and yet a third of respondents 'got it wrong'. I find this worrying and it needs further consideration and discussion.

Reply: Thank you for your comment. We agree that this limitation needs to be clarified. We reworded and added details on this issue, the text describing it under Limitations now says: “Similarly, the occurrence of suspected inverse rankings is an indicator that the instructions and visual design of the survey need improvement.”

Where:

459-461

____________________________

Results

____________________________

7. For such a simple task, the analysis is rather complicated! Numerous means of ranking attributes are reported but no indication is given as to which is most useful or most valid. It is seemingly entirely exploratory, but then there is seemingly also no conclusion / no recommendation from the work?

Reply: Thank you for pointing out this important issue. We think that there is not a “one size fits” all metric for this problem hence the presentation of multiple metrics, as they all have their advantages and disadvantages which we discuss under Ranking of importance and comparison with other studies. Please also see also R2, 15. We present the clarified conclusions under Conclusion and partially under Future research.

Where:

404-414

____________________________

Discussion / conclusion:

____________________________

8. I am at a bit of a loss to see what the take home message of this paper is? The methods appear problematic, there is no clear recommendation of which five attributes should be taken forward to develop into a measure. It appears that other methods and other samples have been used to address the same question, but no indication of whether that gives us a definitive conclusion either. So I cannot see how any of the research results presented actually inform the overall research objective / future aspirations? Indeed the authors seem unsure themselves saying "This result may inform the continued development of the CALY measure".

Reply: Thank you for highlighting the unclarities regarding the take home message and the relation to the overall project. We clarified the conclusions to explicitly state the relation to future research: “The analysis shows that health, social relations, financial situation, and potentially knowledge may be relevant capabilities for the Swedish context. and for inclusion in the CALY measure. This result informs the continued development of the CALYs measure.’ We also provide more details under Future research how the overall research project profits from the findings. Please see also R1, 4th minor for more details on these clarifications.

Where:

478-482

Submitted filename: commentresponse_table_2020915.docx

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9 Nov 2020

Towards capability-adjusted life years in public health and social welfare: Results from a Swedish survey on ranking capabilities

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18 Nov 2020

PONE-D-20-06320R1

Towards capability-adjusted life years in public health and social welfare: Results from a Swedish survey on ranking capabilities

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Table 1

Participant’s characteristics.

Characteristic	Category	N	Proportion
Gender	Woman	74	0.64
	Man	39	0.34
	NA	2	0.02
Field	Medicine	29	0.25
	Public Health	40	0.35
	Social science	21	0.18
	Other	9	0.08
	NA	16	0.14
Age group	30 and lower	3	0.03
	30–39	43	0.37
	40–49	26	0.23
	50–59	24	0.21
	60 and over	19	0.17
Overall		115

Table 2

Win count balance for each pair of capabilities.

Ranking of importance	Win count balance (of the total 115 pairwise comparisons)										Ranked 1 to 5
	Health	Social relations	Financial situation	Knowledge	Occupation	Time	Security	Political resources	Housing	Living environment
Health	0	39	51	61	61	49	59	47	55	55	87
Social relations	–39	0	23	27	41	27	31	37	35	53	75
Financial situation	–51	-23	0	5	13	15	13	5	25	27	67
Knowledge	–61	–27	–5	0	23	11	3	23	17	23	56
Occupation	–61	–41	–13	–23	0	1	17	5	29	11	49
Time	–49	–27	–15	–11	–1	0	1	–3	3	19	51
Security	–59	–31	–13	–3	–17	–1	0	9	–5	5	52
Political resources	–47	–37	–5	–23	–5	3	–9	0	–3	9	50
Housing	–55	–35	–25	–17	–29	–3	5	3	0	–7	48
Living environment	–55	–53	–27	–23	–11	–19	–5	–9	7	0	40

The left section is the number of times (win count balance) the capability in a row was ranked ahead of (positive values) or behind (negative values) the capability in the column for each pair of capabilities given by row and column. The right section is the cumulative number of times a capability was ranked 1 to 5.

Table 3

Median ranks.

	Overall	Gender		Research field				Age group
Capability	Overall	Men	Women	Medicine	Public health	Social science	Other	30–39	40–49	50–59	60+
n	115	39	74	29	40	21	9	43	26	24	19
Health	2	1	2	1	2	3	1	2	2	1.5	1
	(CI 1–2)	(CI 1–2)	(CI 1–3)	(CI 1–2)	(CI 1–3)	(CI 1–6)	(CI 1–5)	(CI 1–3)	(CI 1–2.5)	(CI 1–5)	(CI 1–2)
Social relations	4	4	3	3	3	4	6	5	3	2.5	2
	(CI 3–5)	(CI 3–5)	(CI 3–5)	(CI 2–6)	(CI 2–5)	(CI 2–7)	(CI 2–7)	(CI 4–6)	(CI 2–5)	(CI 2–6)	(CI 2–5)
Financial situation	5	5	5	5	6	5	4	5	5.5	5	4
	(CI 5–6)	(CI 4–5)	(CI 5–6)	(CI 4–6)	(CI 5–6)	(CI 4–7)	(CI 3–8)	(CI 5–6)	(CI 4.5–6.5)	(CI 4–5)	(CI 4–6)
Knowledge	6	6	5.5	6	5	6	6	6	5.5	5	5
	(CI 5–6)	(CI 5–7)	(CI 5–6)	(CI 4–6)	(CI 4–7)	(CI 5–7)	(CI 4–8)	(CI 5–6)	(CI 3.5–7)	(CI 4–7)	(CI 3–7)
Occupation	6	6	6	5	7	6	4	7	5.5	6	6
	(CI 5–7)	(CI 5–7)	(CI 5–7)	(CI 4–7)	(CI 6–7)	(CI 5–8)	(CI 2–9)	(CI 5–8)	(CI 4–7)	(CI 4–7)	(CI 4–7)
Time	6	7	5.5	7	6	6	8	5	4	7.5	7
	(CI 5–7)	(CI 6–8)	(CI 4–7)	(CI 4–8)	(CI 4.5–8)	(CI 3–7)	(CI 3–9)	(CI 4–7)	(CI 3.5–7)	(CI 5.5–9)	(CI 6–9)
Security	6	7	6	6	6	6	6	6	7.5	6.5	7
	(CI 5–7)	(CI 4–8)	(CI 5–7)	(CI 4–8)	(CI 4–8)	(CI 4–8)	(CI 4–9)	(CI 4–7)	(CI 4–8.5)	(CI 4–8)	(CI 4–9)
Political resources	6	6	6	6	5	6	8	6	7	6	6
	(CI 5–7)	(CI 4–7)	(CI 5–7)	(CI 6–9)	(CI 4–7)	(CI 3–9)	(CI 3–10)	(CI 4–8)	(CI 6–9)	(CI 4–7)	(CI 4–8)
Housing	7	8	6	7	8	8	5	5	8.5	6.5	8
	(CI 5–8)	(CI 5–9)	(CI 5–8)	(CI 5–8)	(CI 4.5–9)	(CI 3–9)	(CI 2–6)	(CI 4–8)	(CI 6–9)	(CI 5–8)	(CI 5–9)
Living environment	7	7	7	8	7	6	8	6	7	6.5	8
	(CI 6–7)	(CI 6–8)	(CI 6–7.5)	(CI 6–8)	(CI 5.5–8)	(CI 4–7)	(CI 3–10)	(CI 5–7)	(CI 5.5–8)	(CI 5–8)	(CI 7–9)

Per strata, 95% confidence intervals (CIs) were calculated with bootstrapping based on 10,000 resamples. The number of rankings per subgroup is denoted by n. In the case of an even number of observations, .5 fractions could occur because the median was calculated by averaging the observations positioned at n/2 and n/2 +1.

Table 4

Mean ranks.

	Overall	Gender		Research field				Age group
Capability	Overall	Men	Women	Medicine	Public health	Social science	Other	30–39	40–49	50–59	60+
n	115	39	74	29	40	21	9	43	26	24	19
Health	3.43	2.64	3.8	2.76	3.38	3.86	2.56	3.84	2.69	3.75	2.63
	(CI 2.8–4.1)	(CI 1.8–3.6)	(CI 3–4.6)	(CI 1.8–3.9)	(CI 2.4–4.4)	(CI 2.5–5.2)	(CI 1–4.6)	(CI 2.8–4.9)	(CI 1.9–3.7)	(CI 2.4–5.2)	(CI 1.5–4.1)
Social relations	4.48	4.54	4.47	4.14	3.98	5	5.22	5.21	4.08	4.38	3.42
	(CI 3.9–5)	(CI 3.7–5.4)	(CI 3.8–5.2)	(CI 3.1–5.3)	(CI 3.2–4.8)	(CI 3.8–6.3)	(CI 3.6–6.9)	(CI 4.3–6.1)	(CI 3.1–5.1)	(CI 3.1–5.7)	(CI 2.5–4.4)
Financial situation	5.37	4.74	5.64	5.17	5.65	5.57	4.78	5.63	5.62	5.12	4.74
	(CI 5–5.8)	(CI 4.1–5.4)	(CI 5.1–6.1)	(CI 4.6–5.8)	(CI 5–6.3)	(CI 4.6–6.7)	(CI 3.3–6.2)	(CI 5–6.3)	(CI 4.7–6.5)	(CI 4.4–5.8)	(CI 3.8–5.7)
Knowledge	5.47	5.59	5.39	5.38	5.35	5.81	5.89	5.72	5.31	5.46	4.84
	(CI 5.1–5.9)	(CI 4.9–6.2)	(CI 4.9–5.9)	(CI 4.7–6.1)	(CI 4.7–6)	(CI 4.9–6.7)	(CI 4.8–7)	(CI 5.1–6.3)	(CI 4.5–6.2)	(CI 4.5–6.4)	(CI 3.9–5.8)
Occupation	5.83	6	5.69	5.28	6.47	6.1	4.78	6.23	5.58	5.58	5.42
	(CI 5.4–6.3)	(CI 5.2–6.7)	(CI 5.1–6.2)	(CI 4.4–6.2)	(CI 5.9–7.1)	(CI 5.1–7)	(CI 3–6.7)	(CI 5.5–7)	(CI 4.7–6.5)	(CI 4.7–6.5)	(CI 4.5–6.4)
Time	5.86	6.33	5.58	6.17	5.95	5.1	6.78	5.4	5.12	6.67	7.16
	(CI 5.3–6.4)	(CI 5.5–7.2)	(CI 4.9–6.2)	(CI 5.1–7.2)	(CI 5.1–6.8)	(CI 3.9–6.4)	(CI 5–8.3)	(CI 4.5–6.3)	(CI 4.1–6.2)	(CI 5.4–7.8)	(CI 6.2–8.1)
Security	6	6.15	5.96	5.97	5.83	5.67	6.56	5.67	6.31	6.04	6.21
	(CI 5.5–6.5)	(CI 5.3–7.1)	(CI 5.3–6.6)	(CI 5–6.9)	(CI 4.8–6.8)	(CI 4.6–6.7)	(CI 5.1–8)	(CI 4.9–6.5)	(CI 5.1–7.5)	(CI 4.9–7.1)	(CI 4.9–7.5)
Political resources	6.01	6.03	6	6.83	5.42	5.76	7.11	5.86	6.73	5.58	6.11
	(CI 5.5–6.5)	(CI 5.1–6.9)	(CI 5.3–6.7)	(CI 5.8–7.8)	(CI 4.6–6.2)	(CI 4.3–7.2)	(CI 5.2–8.8)	(CI 4.9–6.8)	(CI 5.7–7.7)	(CI 4.4–6.8)	(CI 4.9–7.3)
Housing	6.21	6.44	6.2	6.52	6.58	6.33	4.67	5.6	7	6.25	6.84
	(CI 5.6–6.8)	(CI 5.4–7.4)	(CI 5.5–6.9)	(CI 5.5–7.4)	(CI 5.5–7.5)	(CI 4.9–7.7)	(CI 3.2–6.2)	(CI 4.7–6.6)	(CI 5.8–8.1)	(CI 5.1–7.3)	(CI 5.4–8.2)
Living environment	6.35	6.54	6.27	6.79	6.4	5.81	6.67	5.84	6.58	6.17	7.63
	(CI 5.9–6.8)	(CI 5.7–7.3)	(CI 5.7–6.8)	(CI 5.9–7.7)	(CI 5.6–7.2)	(CI 4.6–7)	(CI 4.7–8.4)	(CI 5–6.6)	(CI 5.6–7.5)	(CI 5.2–7.1)	(CI 6.7–8.5)

Per strata, 95% CIs were calculated with bootstrapping based on 10,000 resamples. The number of rankings per subgroup is denoted by n.