Elsevier

Social Science & Medicine

Volume 63, Issue 9, November 2006, Pages 2367-2380
Social Science & Medicine

Gender differences in health-related quality of life among the elderly: The role of objective functional capacity and chronic conditions

https://doi.org/10.1016/j.socscimed.2006.06.017Get rights and content

Abstract

Although worse Health-Related Quality of Life (HRQL) among women has been widely described, it remains unclear whether this is due to differential reporting patterns, or whether there is a real difference in health status. The objective of this study was to evaluate to what extent gender differences in HRQL among the elderly might be explained by differences in performance-based functional capacity and chronic conditions, using the conceptual model of health outcomes as proposed by Wilson and Cleary. Data are from a cross-sectional home survey of 872 surviving individuals from an elderly cohort representative of Barcelona's general population. Complete valid data for these analyses were obtained from 62% of the subjects (n=544). The evaluation included the Nottingham Health Profile (NHP), a generic measure of HRQL; three performance-based functional capacity tests (balance, chair-stand, and walking tests); and a standardized list of self-reported chronic conditions. A series of multiple linear regression models were built with the total NHP score as the dependent variable, with gender, socio-demographic information, performance-based functional capacity and chronic conditions included sequentially, as independent variables. Women (65.4%) showed worse results than men on HRQL (mean of NHP total score 28.3 vs 16.7, p<0.001) and functional capacity (mean of summary score 7.1 vs 8.3, p<0.001). Functional capacity, arthritis, back pain, diabetes, and depression were significantly associated to the NHP total score in the final regression model, which explained 42% of the variance. Raw differences by gender in the total NHP score were 11.5 points (p < 0.001), but decreased to a non-significant 3.2 points (p=0.18) after adjusting for all the other variables. In conclusion, our data suggest that worse reported HRQL in elderly women is mainly due to a higher prevalence of disability and chronic conditions.

Introduction

The elderly population is increasing both in absolute and relative terms. In developed countries women live on average 6–8 years longer than men, leading to an increasing gender gap with age (WHO, 2000). Therefore a gender perspective of health determinants needs to be taken into account. In fact, gender differences have already been reported for several health indicators and related issues. Also, older women are substantially more likely to experience functional impairment in mobility and personal self-care than men of the same age. And health statistics routinely show the paradox of a higher morbidity and health service use for women, while mortality rates are higher for men (Arber & Cooper, 1999; Macintyre, Hunt, & Sweeting, 1996; Verbrugge, 1989).

Focusing on Health-Related Quality of Life (HRQL), gender differences with consistently worse results among women have been widely described in many different populations independently of the used instrument (Alonso, Anto, & Moreno, 1990; Emery et al., 2004; Hopman et al., 2000; Michelson, Bolund, Nilsson, & Brandberg, 2000; Wijnhoven, Kriegsman, Snoek, Hesselink, & de Haan, 2003). To what extent these differences can be attributed to social and biological factors is yet unclear. From a sociological perspective, it has been hypothesized that as a result of different roles taken by gender, individuals may have a different way of perceiving symptoms and the illness process, leading to an over-estimation of morbidity in women (van Wijk & Kolk, 1997). Men would be socialized to ignore physical discomfort and are less likely to seek medical care for perceived symptoms, thus obtaining treatment when the condition is more advanced (Verbrugge, 1982; Spiers, Jagger, Clarke, & Arthur, 2003). From a biomedical point of view, reported differences between men and women reflect the presence of medical conditions and disability (Hazzard, 1985; Kanner et al., 1994; Karim & Burns, 2003; Parker & Brotchie, 2004).

Most of the literature about determinants of gender differences in perceived health has focused mainly on social factors (Arber & Ginn, 1993; Artazcoz, Cortes, Moncada, Rolhlfs, & Borrell, 1999; Denton, Prus, & Walters, 2004; Verbrugge, 1989). Only a few studies have addressed a biomedical perspective to test whether gender differences in health, as measured by questionnaires, can be explained by medical conditions and/or observable physical limitations in the general population. One recent study concluded that socio-demographic and lifestyle factors may explain a substantial part of the differences between men and women in HRQL, while chronic morbidity and health services use to play a lesser role (Guallar-Castillon, Sendino, Banegas, Lopez-Garcia, & Rodriguez-Artalejo, 2005). This seems to be contradicted by findings from other studies of the elderly based on disability measures, which suggest that worse reports from older women do, in fact, reflect higher functional limitations (Arber & Cooper, 1999; Ferrer, Lamarca, Orfila, & Alonso, 1999; Merrill, Seeman, Kasl, & Berkman, 1997; Wray & Blaum, 2001). In addition, there are several isolated findings that would support the influence of biomedical factors, such as the different patterns in chronic conditions, and higher rates of survival with disability described among elderly women (Ettinger et al., 1994; Fried, Ettinger, Lind, Newman, & Gardin, 1994; Guralnik, Leveille, Hirsch, Ferrucci, & Fried, 1997). Disability in women has been shown to be more frequently related to non-fatal or minor but disabling conditions, such as arthritis, while disability in men is more related to fatal conditions, such as cardiovascular or lung diseases. However, again we find that medical literature shows complex and sometimes contradictory findings, with the magnitude and direction of gender differences varying depending on the particular diagnosis or age (Jagger & Matthews, 2002; von Strauss, Aguero-Torres, Kareholt, Winblad, & Fratiglioni, 2003).

A general model of patients’ outcomes proposed by Wilson and Cleary (Wilson & Cleary, 1995) conceptualizes the integration of the social and the biomedical paradigms and places measures of health as existing on a continuum of increasing complexity. At one end of the continuum there are biological measures such as serum albumin levels and hematocrit, then symptoms and physical functioning, and then on to more complex and integrated measures such as general health perceptions to overall HRQL. In fact HRQL has been increasingly used as a health status outcome measure in the elderly. It is associated with acute hospital admissions and other health services use (Harris, Kovar, Suzman, Kleinman, & Feldman, 1989), with institutionalization (Branch & Jette, 1982), and with subsequent dependency or death (Kaplan, Barell, & Lusky, 1988; Warren & Knight, 1982). The influence of the environment (social, economic or psychological support) and of the individual's characteristics (values or motivation, among others) affect every step of the continuum of health, showing HRQL to be influenced not only by health conditions, but also by social or individual characteristics, that also modify the previous health variables, such as symptoms, conditions or physical functioning. In this sense, results from various studies (Arber & Cooper, 1999; Guallar-Castillon et al., 2005), support this influence of social factors or lifestyles on HRQL or perceived general health.

The objective of the present study was to evaluate the effect on HRQL differences by gender of performance-based functional capacity, chronic conditions, and socio-demographic variables, among an elderly general population. We adapted to this proposed objective the Wilson and Cleary's patients’ outcomes model. This adaptation is shown in Fig. 1. We hypothesized that if HRQL gender differences are due to different ways of reporting or perceiving general health, they should remain after adjusting for the described pathways (biological and physiological variables, and functional status). On the contrary, if women perceived worse general health as a result of an objective worse health condition, then gender differences in HRQL would be largely explained by these worse health conditions.

Section snippets

Population

A cohort of non-institutionalized residents aged 65 and older included in the 1986 “Health Interview Survey of Barcelona”, Spain, (population=1.5 million inhabitants) was followed (details of the study are described elsewhere (Ferrer et al., 1999). The data presented here are based on an evaluation conducted between June 1993 and June 1994, after a median of 7.5 years of follow-up, since both HRQL and performance-based functional capacity tests were measured only at that time. From the 1315

Results

From the 544 individuals who completed both the NHP and the performance test, 356 were women (65.4%), with a mean age of 78.4 (SD=4.8) for women and a mean age of 78.8 (SD=5.2) for men. Table 1 compares characteristics between the sample with complete data (n=544) and those presenting missing data that were excluded from the analyses (n=191). The proportion of women in the group with complete data is 65%, compared to 68% among excluded individuals (p=0.51). There were no statistically

Discussion

The purpose of this study was to assess the extent to which performance-based functional capacity, as well as reported chronic health conditions could explain the HRQL differences by gender in a community-dwelling elderly cohort from the city of Barcelona. As expected, elderly women showed worse total NHP score than men as well as in all of the dimension scores. The main finding of this study is that gender differences in the total NHP score were largely explained by the higher prevalence of

Acknowledgments

This study was supported in part by funds from Fondo de Investigación Sanitaria (91/0629), Instituto de Salud Carlos III (network of excellence RCESP—C03/09), and DURSI Government of Catalonia (2001 SGR 00405). The authors would like to thank Maxine Hollewell for editorial assistance in the preparation of this article.

References (56)

  • M. Heliövaara et al.

    Reliability and validity of interview data on chronic diseases the mini-finland health survey reliability and validity of interview data on chronic diseases. The Mini-Finland Health Survey

    Journal of Clinical Epidemiology

    (1993)
  • E.F. Juniper et al.

    Determining a mininal important change in a disease-specific quality of life questionnaire

    Journal of Clinical Epidemiology

    (1994)
  • D.M. Kriegsman et al.

    Self-reports and general practitioner information on the presence of chronic diseases in community dwelling elderly. A study on the accuracy of patients’ self-reports and on determinants of inaccuracy

    Journal of Clinical Epidemiology

    (1996)
  • R. Lamarca et al.

    Performance of a perceived health measure in different groups of the population: A comprehensive study in Spain

    Journal of Clinical Epidemiology

    (2001)
  • S. Macintyre et al.

    Do women ‘over-report’ morbidity? Men's and women's responses to structured prompting on a standard question on long standing illness

    Social Science & Medicine

    (1999)
  • S. Macintyre et al.

    Gender differences in health: Are things really as simple as they seem?

    Social Science & Medicine

    (1996)
  • L.M. March et al.

    Clinical validation of self-reported osteoarthritis

    Osteoarthritis and Cartilage

    (1998)
  • I. Rohlfs et al.

    The importance of the gender perspective in health interview surveys

    Gaceta Sanitaria

    (2000)
  • C.M. van Wijk et al.

    Sex differences in physical symptoms: The contribution of symptom perception theory

    Social Science & Medicine

    (1997)
  • J. Alonso et al.

    Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

    Acta Psychiatrica Scandinavica Supplementum

    (2004)
  • J. Alonso et al.

    Disability and quality of life impact of mental disorders in Europe: Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

    Acta Psychiatrica Scandinavica Supplementum

    (2004)
  • J. Alonso et al.

    Spanish version of the Nottingham Health Profile: Translation and preliminary validity

    American Journal of Public Health

    (1990)
  • J. Alonso et al.

    Health-related quality of life associated with chronic conditions in eight countries. Results from the International Quality of Life Assessment (IQOLA) project

    Quality of Life Research

    (2004)
  • J. Alonso et al.

    The Spanish version of the Nottingham Health Profile: a review of adaptation and instrument characteristics

    Quality of Life Research

    (1994)
  • P.M. Bentler

    Comparative fit indexes in structural models

    Psychological Bulletin

    (1990)
  • L.G. Branch et al.

    A prospective study of long-term care institutionalization among the aged

    American Journal of Public Health

    (1982)
  • T.L. Bush et al.

    Self-Report and medical record report agreement of selected medical conditions in the elderly self-report and medical record report agreement of selected medical conditions in the elderly

    American Journal of Public Health

    (1989)
  • C.F. Emery et al.

    Gender differences in quality of life among cardiac patients

    Psychosomatic Medicine

    (2004)
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