Differences in quality of life between women and men in the older population of Spain
Introduction
Health-related quality of life (HRQL) provides a subjective overview of the state of health of individuals. Worse HRQL is associated with higher mortality (Ries, Kaplan, Limbreg, & Prewitt, 1995) and a greater use of healthcare services (Conelli, Philbrick, Smith, Kaiser & Wymer, 1989; Siu, Reuben, Ouslander & Osterweil, 1993). Women tend to report a poorer HRQL than men, both in selected samples of subjects (Meléndez Hernández, Montero Herrero, Jiménez Sánchez & Blanco Montagut, 2001; Walters, Munro & Brazier, 2001) and in the general population (Alonso, Regidor, Barrio, Prieto, Rodríguez, & De la Fuente, 1998; Azpiazu et al., 2003; Hopman et al., 2000; Loge & Kaasa, 1998; López García et al., 2003b; Scott, Tobias, Sarfati & Haslett, 1999; Sullivan & Karlsson, 1998). Although there is a substantial amount of literature on possible explanatory factors of the greater morbidity and disability, and worse subjective health reported by women (Rohlfs, Borrell & Fonseca, 2000; Ruiz & Verbrugge, 1997), very few studies have specifically addressed the possible determinants of the differences in HRQL between men and women. Moreover, such studies are particularly infrequent among samples representative of the older adult population (Arber & Cooper, 1999; Arber & Ginn, 1993; Dahl & Birkelund, 1997).
The determinants of the differences in health between women and men may differ with the measure of health used (Macintyre, Hunt & Sweeting, 1996) and, consequently, the results obtained on subjective health or disability may not apply to HRQL. Similarly, factors that explain differences in health status may vary across the life cycle (Macintyre et al., 1996). The study of such factors in older adults is particularly relevant. First, because in this population segment, whose size is progressively growing, health needs are much greater than among the young; second, because the predominance of women over men increases with age and HRQL is worse among the former.
Furthermore, differences in HRQL between women and men may change with population's cultural values and degree of economic development, which differ between southern European countries and those in the north of Europe and North America. Cultural values may influence not only the meaning, interpretation, knowledge and potential determinants of health and disease, but also the manner of reporting them. Moreover, cultural values and degree of economic development influence women's incorporation to paid work and fulfillment of their social role, with possible effects on differences in HRQL between sexes (Annandale & Hunt, 2001).
Lastly, theories explaining the differences in health between women and men include strictly biological factors (genes, anatomy, hormones, reproductive history, etc.), factors stemming from women's social role (social network and support, non-paid work at home, etc.) and mixed factors that are a combination of the previous two (health-related lifestyles, use of healthcare services, mental health disorders, etc.) (Dahl & Birkelund, 1997). The contribution of these types of factors to differences in HRQL between women and men depends on two elements: (a) the effect of each on health, something that may vary with sex (e.g., whereas tobacco and alcohol have a greater influence on men's health, sedentary lifestyle and obesity have a greater influence on women's health) (Denton & Walters, 1999); and (b) the frequency and distribution of such factors in each sex. Both elements may vary with the country, culture, age and calendar time (Hunt, 2002; Wiggins et al., 2002).
Accordingly, this study examines the contribution of sociodemographic factors, lifestyle, social network, chronic morbidity and use of healthcare services to the poorer HRQL of women, as compared to that of men, in the older population of Spain; it also ascertains whether the contribution of such factors changed with age. To our knowledge this is the first study of its type conducted in a European Mediterranean country.
Section snippets
Study design and subjects
This was a cross-sectional survey covering a sample of 4000 subjects representative of the non-institutionalized Spanish population aged 60 years and over. The study was approved by the Clinical Research Ethics Committee of the “La Paz” University Hospital in Madrid.
Study subjects were selected through probabilistic multistage cluster sampling. Firstly, clusters were stratified by region of residence and size of town. Thereafter, census sections were selected at random in each cluster, followed
Results
The study sample comprised 1768 (54.2%) women and 1492 (45.8%) men, with a mean age of 72.2 and 70.8 years, respectively.
Table 1 shows the distribution by sex of the variables of interest organized into four groups, i.e., sociodemographic, lifestyle, social network and health-related. Differences between women and men (p<0.05) were observed for most of the variables, except for size of town of residence and use of healthcare services. A total of 80.8% of men, versus 45.6% of women, were
Discussion
Among the older population of Spain, women have a substantially worse HRQL than men, on both the physical and mental scales. The study variables had an impact on gender differences in HRQL only for a minority of dimensions. However, sociodemographic factors, such as not being head of the family and having a lower educational level, and lifestyle-related variables, such as a higher BMI and less physical activity, may partly explain the worse score registered by women on the general health and
Acknowledgements
This work was funded, in part, by a grant (Dossier 24/02) from the Instituto de la Mujer, Ministerio de Trabajo y Asuntos Sociales and by ISCIII (Red de Centros RCESP C03/09). During this study, Esther Lopez-García was the recipient of a Fulbright fellowship from Secretaría de Estado de Educación y Universidades, Ministerio de Educación y Cultura de España, y el Fondo Social Europeo.
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