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