Age and sex differences in the association between access to medical care and health outcomes among older Chinese

Background

Whether the association between access to medical care and health outcomes differs by age and gender among older adults in China is unclear. We aimed to investigate the associations between self-reported inadequate access to care and multiple health outcomes among older men and women in mainland China.

Methods

Based on four latest waves available so far from a national longitudinal study in mainland China in 2005–2014, we used multilevel random-effect logistic models to estimate the contemporaneous relationships between inadequate access to care and disabilities in instrumental activities of daily living (IADL) and cognitive impairment in men and women at ages 65–74, 75–84, 85–94, and 95+, separately. We also used multilevel hazard models to investigate the relationships between reported access to care and mortality in 2005–2014. Nested models were used to adjust for survey design, sociodemographic background, enrollment in health insurance, and health behaviors.

Results

Approximately 6.5% of older adults in China reported inadequate access to care in the period of 2005–2014; and the percentages increased with age and were higher among women at older ages (≥75?years). Overall, older adults with self-reported inadequate access to care had greater odds of IADL and ADL disabilities and cognitive impairment than those with adequate access to healthcare. The elevated odds ratios (ORs) in men were higher in middle-old (75–84) and old-old (85–94) age groups compared to other age groups; whereas the elevated ORs in women were higher in young-old (65–74) and middle-old (75–84) age groups. The relationship between access to care and the health outcomes was generally weakest at the oldest-old ages (95+). Inadequate access to care was also linked with higher mortality risk, primarily in adults aged 75–84, and it was somewhat more pronounced in women than in men.

Conclusions

Increased odds of physical disability and cognitive impairment and increased risk of mortality are linked with inadequate access to care. The associations were generally stronger in women than in men and varied across age groups. The findings of the present study have important implications for further improving access to health care and improving health outcomes of older adults in China.

     

Health among the oldest-old in China: Which living arrangements make a difference?

This study aims to (1) examine the association of living arrangements and health among oldest-old Chinese, and (2) investigate gender differences in the association of living arrangements and health. Data were from the first two waves of the Chinese Longitudinal Healthy Longevity Survey, which included 9093 Chinese averaging 92 years old. Living arrangements had six mutually exclusive categories: living alone, with spouse, with children, with spouse and children, with others and in institutions. Using multinomial logistic regression, we found that baseline living arrangements are significantly associated with mortality, activities of daily living (ADL) disability, and self-rated health at Wave 2, controlling for baseline health, sociodemographic characteristics and availability of children. Further, the linkages between living arrangements and mortality vary by gender. Among the different living arrangements, having a spouse in the household (either with a spouse only or with both a spouse and children) provides the best health protection. Living alone and living with children are associated with both health advantages and disadvantages. Institutional living lowers mortality risk for men but not women. Living with others provides the least health benefits. Our study has extended the research on living arrangements and health to a unique population—the oldest-old in China—and clarified the health advantages and disadvantages of different living arrangements. Future research should examine the mechanisms linking living arrangements and health, and the experience of institutional living for men and women in China.     

Gender disparity of successful aging in Taiwan

The purpose of this longitudinal study was to examine the association of gender on successful aging during a 6-year follow-up study. Data were drawn from the 1989, 1993, 1996, and 1999 Survey of Health and Living Status of the Elderly in Taiwan, a national representative population survey of 4,049 participants aged 60 years or older; 43% were women. Successful aging indicators were defined as physical (absence of disease and physical disability), mental (normal cognitive function and absence of depression), and social (good social support and participation in productive activities). Gender differences related to successful aging during the 6 years were analyzed with Cox proportional hazards regression model. Significant disparities were found between elderly men and women in activities of daily living (ADL), instrumental activities of daily living (IADL), cognitive function, depressive symptoms, social support and productive activities. When the data included individuals who were deceased, elderly women showed better maintenance of ADL and less vulnerability to IADL impairment than elderly men. However, when the analysis included only survivors during the follow-up, the elderly were more likely to be impaired in IADL and cognitive function, have depressive symptoms, and lack engagement in productive activities. Cumulative disadvantage was associated with health disparities in elderly women. This research demonstrates the need to develop gender-sensitive policies.     

The social context of health selection: a longitudinal study of health and employment

Health selection out of the labour force has received considerable attention by analysts attempting to disentangle the "true" biological dimensions of ill-health from its social meaning. Rejecting this dualistic separation, we argue that the effect of health on labour force participation is an inherently social process reflecting differential access to material and symbolic rewards that are structured by social position. Using longitudinal data from the US-based Panel Study of Income Dynamics, we examine the extent to which structural arrangements, including those designated by gender, race, education and age, differentially affect the risk of a labour market exit when health is compromised. Individuals employed at entry into the study (from 1984-1990) were followed for the duration of the study or until they left the labour force. Analyses were stratified by gender and age (25-39 and 40-61 years at baseline). We found suggestive evidence that the hazard of labour market exit in the context of perceived ill-health depended on gender, race and education, but in ways that were not constant across each of these social positions. For example, men may be more vulnerable to the labour market effects of poor health, but only in the younger group, black men were less likely to leave the labour force than white men, and education mattered, but only among younger women and older men. While these patterns may reflect differential access to disability pensions or other work-related benefits, we suggest that a more detailed analysis of trajectories of health and employment. as well as the meaning of health states would be useful in further elucidating the social dimensions of health selection.     

Work and leisure time physical activity assessed using a simple, pragmatic, validated questionnaire and incident cardiovascular disease and all-cause mortality in men and women: The European Prospective Investigation into Cancer in Norfolk prospective population study

BACKGROUND: The health benefits of physical activity are well established, but the overall amount of physical activity associated with cardiovascular and other health outcomes, and whether the relationships are similar in men and women and at different ages is still debated. This may be partly related to different methods for assessing physical activity. Most studies have focused on leisure time physical activity. METHODS: We examined the prospective relationship between usual physical activity, taking into account both leisure and work activity, using a simple, pragmatic, four-point rating scale validated against heart rate monitoring, and cardiovascular disease incidence and total mortality after an average 8 years follow-up in 22,191 community living men and women aged 45-79 years with no known cardiovascular disease or cancer at baseline. RESULTS: The relative risks (95% confidence interval) for all-cause mortality (1,553 deaths) for men and women who were moderately inactive, moderately active, and active compared with those who were inactive were 0.83 (0.73-0.95), 0.68 (0.58-0.80), and 0.68 (0.57-0.81), respectively, after adjusting for age, sex, systolic blood pressure, blood cholesterol, cigarette smoking, alcohol intake, diabetes, body mass index, and social class. The relationships were also consistent for cardiovascular disease incidence (3,079 events), in subgroups stratified by age, sex, body mass index, smoking status and social class, and after excluding deaths in the first 2 years. The combined scale was more consistently associated with mortality than the individual work and leisure time components separately. CONCLUSIONS: When both work and leisure time physical activity patterns are taken into account, using a simple, pragmatic, validated questionnaire feasible for use in clinical and public health practice, even very moderate levels of usual physical activity are associated with significantly reduced risk of mortality and cardiovascular disease in men and women in the general population and potential population attributable impact of 14% for inactive compared with active levels. These findings may encourage efforts to increase physical activity levels not only in leisure time but also in usual daily working life.     

Prevalence of health conditions and predictors of mortality in oldest old Mexican Americans and non-Hispanic whites

BackgroundThe oldest old represent a unique group of older adults. This group is rapidly growing worldwide and yet there are gaps in the knowledge related to their health condition. Ethnic differences in disease prevalence and mortality must be understood to better care for the oldest old.ObjectiveTo compare prevalence of common health conditions and predictors of mortality in oldest old Mexican Americans and non-Hispanic whites.MethodsThis study included 568 community-dwelling Mexican Americans (MA) aged 85 years and older from the Hispanic Established Population for the Epidemiological Study of the Elderly 2004–2005 and 933 non-Hispanic whites (NHW) of the same age from the Health and Retirement Study 2004. Measures included sociodemographic variables, self-reported medical conditions, activities of daily living (ADLs), and instrumental activities of daily living. Logistic regression analysis was used to examine 2-year mortality in both populations.ResultsHeart attack was significantly more prevalent in oldest old NHW compared with MA, regardless of gender. Conversely, diabetes was significantly more prevalent among MA men and women compared with their NHW counterparts. Compared with NHW men, MA men had significantly higher prevalence of cognitive impairment and hypertension. Additionally, prevalence of hip fracture was significantly higher for MA women compared with NHW women. Significant differences in ADL disability were observed only between both groups of women, whereas significant differences in instrumental activities of daily living disability were observed only between men. MA men and women had higher prevalence of obesity compared with NHW. Predictors of 2-year mortality for both ethnic groups included older age, male gender, and ADL disability. Cognitive impairment was a mortality predictor only for NHW. Similarly, lung disease was a predictor only for MA.ConclusionHealth-related conditions that affect the oldest old vary by gender and ethnicity and entail careful evaluation and monitoring in the clinical setting. Better care requires inclusion of such differences as part of the comprehensive evaluation of the oldest old adults.     

Individual-level measures of social capital as predictors of all-cause and cardiovascular mortality: a population-based prospective study of men and women in Finland

Individual-level social capital was assessed for prediction of mortality in a nationally representative study population aged 30–99 years at the baseline. A total of 90% of the original sample had participated in a comprehensive health examination (Mini-Finland Health Survey) in 1978–1980. After the first 5 years of the 24-year follow-up period, 1,196 of 3,014 men and 1,280 of 3,689 women died. Individual-level social capital was determined by factor analysis that revealed three factors: residential stability, leisure participation and interpersonal trust. Factor analysis showed a gender difference in leisure social participation. All-cause mortality and cardiovascular mortality were analyzed using Cox proportional hazard models. Adjusted for demographic, life style and biological risk factors, and for health and socio-economic status, leisure participation was associated with reduced all-cause mortality in men (hazard ratio, HR: 0.94; 95% confidence interval, CI: 0.89–1.00). This association seems to be related to economic status in men. Age modifies the effect of interpersonal trust on all-cause mortality in men. In women, leisure participation (HR: 0.96; 95% CI: 0.91–1.00) and interpersonal trust (HR: 0.69; 95% CI: 0.51–0.93) predicted all-cause mortality, and the latter also cardiovascular mortality (HR: 0.93; 95% CI: 0.86–1.00). The associations between individual-level social capital and mortality are gender- and age-related. Understanding the gender and age perspectives appears to be essential for better insight into the interrelations between social capital and health.     

Associations of health practices and social aspects of life with mortality among elderly people in a Japanese rural area

A five-year study of persons aged 65 years and over in a Japanese rural area was conducted to examine associations of health practices and the social aspects of life with mortality. Age- and sex-related changes in the associations were examined. For health practices, constipation among men aged 75 years and over, and never or not annually receiving checkups among women aged 75 years and over were associated with increased mortality risk after adjustment for the initial subjective health status. In contrast to no associations between the social aspects of life and mortality among women aged 65-74 years, social aspects of life were more predictive of mortality than subjective health status and health practices among women aged 75 years and over. In this group, having neither a job nor a family role, membership in a group for the elderly while participating only in group tours and/or lecture meetings or without attending any of the regular activities, and infrequent contact with friends were associated with increased mortality. Among men, increased mortality risk was associated with membership in a group for the elderly while participating only in group tours and/or lecture meetings in the 65-74 year-old group.     

Leisure time physical activity and health-related quality of life: Cross-sectional and longitudinal associations

Studies that relate change in physical activity to change in health-related quality of life in the general population are needed to confirm associations suggested by cross-sectional studies. In the present study, cross-sectional as well as longitudinal associations between leisure time physical activity and health-related quality of life were studied in an apparently healthy population. The present study showed cross-sectional associations between at least moderately intense leisure time physical activity and general health perceptions, vitality, physical functioning and role limitations due to physical health problems. No associations were present for total leisure time physical activity. Change in leisure time physical activity was associated with change in social functioning in men as well as in women, irrespective of the intensity of physical activity. Only in men, change in total leisure time physical activity was associated with change in vitality and general mental health. In our study, cross-sectional associations were not confirmed by longitudinal analyses. Cross-sectional associations were mainly found for physical components of health-related quality of life, whereas longitudinal associations were predominantly observed for mental components of health-related quality of life. Confirmation of our results by those of other studies is needed in order to quantify health promotion messages.     

Associations of self-rated health with different forms of leisure activities among ageing people

Summary Objectives:  This study examined associations between self-rated health and specific forms of leisure activities – i. e. singing in a choir, art painting, playing music; art exhibitions, theatre, movies, concerts; religious events; studying and self-development; voluntary work – and investigated how confounding factors contribute to these associations among ageing people in Finland. Methods:  A postal survey was conducted in 2002 among men and women born in 1926–30, 1936–40 and 1946–50. The final 2,815 participants represented 66% of the original sample drawn, stratified by age, gender, and municipality. Logistic regression analyses were used to investigate associations between specific forms of leisure activities and self-rated health. Results:  Going to art exhibitions, theatre, movies, and concerts among women and studying and self-development among men were significantly positively related to self-rated health, even after adjusting for socioeconomic status (SES), other sociodemographic variables, obesity, and health behaviours. Among women, active participation in religious events and voluntary work were negatively associated with self-rated health. Conclusions:  The association of leisure activities and good self-rated health may differ for genders due to their nature or meaning. Partial support was found for the assumption that leisure activities go together with better self-rated health among ageing people. Submitted: 14 December 2006; Revised: 04 July 2007; Accepted: 02 April 2008     

The relationships between interest for and participation in health screening and risk of mortality: the Japan Collaborative Cohort Study

BACKGROUND: This study examined whether the interest in participation in health screening is associated with reduced mortality in Japan. METHODS: A total of 68,825 subjects, 40-79 years old, in 29 Japanese communities responded to a questionnaire including interest level and participation status in health screening during 1988-1990. Systematic surveillance was completed until the end of 1999, with 660,682 person-years of follow-up, and the causes of death were determined. RESULTS: Men and women with low/no interest in health screening had 24-94% higher mortality from cardiovascular disease (CVD) and all causes. Women, but not men, with non-participation in health screening had 18-24% excess risk of mortality from cardiovascular disease, cancer, and all causes. Men and women with low/no interest and non-participation in health screening had 23-47% excess risk of mortality from cardiovascular disease and all causes. A similar excess risk of mortality was found among men with low/no interest and participation in health screening, but such a trend was less evident among women. CONCLUSION: Men and women with lower interest and women with no participation in health screening were at high risk for cardiovascular disease and all-cause mortality. Additionally, men who participated but had lower interest in health screening are also considered as high risk for cardiovascular disease.     

Dietary quality and lifestyle factors in relation to 10-year mortality in older Europeans: the SENECA study

The single and combined effects of three healthy lifestyle behaviors-nonsmoking, being physically active, and having a high-quality diet-on survival were investigated among older people in the SENECA Study. This European longitudinal study started with baseline measurements in 1988-1989 and lasted until April 30, 1999. The study population consisted of 631 men and 650 women aged 70-75 years from Belgium, Denmark, Italy, The Netherlands, Portugal, Spain, and Switzerland. A lifestyle score was calculated by adding the scores of the lifestyle factors physical activity, dietary quality, and smoking habits. The single lifestyle factors and the lifestyle score were related to mortality. Even at ages 70-75 years, the unhealthy lifestyle behaviors smoking, having a low-quality diet, and being physically inactive were singly related to an increased mortality risk (hazard ratios ranged from 1.2 to 2.1). The risk of death was further increased for all combinations of two unhealthy lifestyle behaviors. Finally, men and women with all three unhealthy lifestyle behaviors had a three- to fourfold increase in mortality risk. These results underscore the importance of a healthy lifestyle, including multiple lifestyle factors, and the maintenance of it with advancing age.     

Changes in leisure time physical activity and risk of all-cause mortality in men and women: the Baltimore Longitudinal Study of Aging

BACKGROUND: Higher levels of leisure time physical activity (LTPA) are associated with reduced mortality. However it is unclear how changes in LTPA over time impact all-cause mortality in men and women. METHODS: From 1958 to 1996 for men (n=1316) and 1978 to 1996 for women (n=776), participants aged 19-90+ years from the Baltimore Longitudinal Study of Aging (Baltimore, MD) were assessed for LTPA at baseline and at approximately 2-year intervals over a mean follow-up of 21.2+/-9.4 years for men and 10.2+/-5.6 years for women. Death occurred in 538 men and 90 women. LTPA was derived from self-reports of time spent in 97 activities converted into MET-min per 24 h and was further grouped into high-, moderate- and low-intensity LTPA. The longitudinal data was analyzed using mixed effects models to determine the rate of change in LTPA at each assessment. Proportional hazard models were used to assess the associations between LTPA at baseline and rate of change in LTPA with all-cause mortality. RESULTS: In younger (<70 years) men, those who reported increases or negligible declines in total and high-intensity LTPA had lower all-cause mortality compared to those with greater declines in LTPA. In older (>or=70 years) men, the association between rate of change in high-intensity LTPA and mortality was similar to that seen in younger men. For women, longitudinal analyses showed neither rates of change in total, high-, moderate- nor low-intensity LTPA were predictive of mortality. CONCLUSIONS: In this health-conscious population, greater longitudinal declines in total and high-intensity LTPA are independent predictors of all-cause mortality in men.     

Gender differences in Israeli physicians' career patterns, productivity and family structure

In the three principal Israeli medical practice settings, men and women physicians in internal and family medicine, cardiology, gastroenterology, geriatrics and general practice (no specialization) were compared on a number of career pattern, productivity and family structure variables. The results revealed gender differences in the functioning and status of men and women physicians similar to those found in other countries. Processes of 'sorting and tracking' of physicians by gender, level and area of specialization and country of medical studies appeared implicated in the concentration of women in 'generalist' specialties and primary care settings and of men in higher status specialties and hospital settings. The nature of professional activities in primary care and hospital settings differed, with research-related activities more common in the hospital setting. This appeared relevant to the higher status achieved by men physicians in the Israeli medical-professional hierarchy. Family roles appeared to affect men and women physicians differently. The findings are compared to those from other countries, and explanations in the Israeli context are proffered.     

Importance of smoking habits for longitudinal and age-matched changes in body mass index: a cohort study of Swedish men and women

BACKGROUND: Previous longitudinal studies of smoking and BMI have focused on smoking cessation. The aim of the present study was to disentangle the effects of long-term smoking on longitudinal changes and age-matched BMI differences (time period effects) in a nation-wide Swedish cohort. METHODS: Men and women (n = 4349) ages 18-73 years reported height, weight, and smoking status for a baseline survey in 1980-1981. Eight and 16 years after baseline, follow-up surveys were conducted for 3244 (75%) of the 4349 subjects. Long-term smokers and long-term nonsmokers were compared with respect to longitudinal changes and age-matched BMI differences. RESULTS: For middle-age adults, the longitudinal increases in BMI were smaller among long-term smokers than long-term nonsmokers regardless of gender. Among the elderly, the longitudinal decrease in BMI was greatest among long-term smokers. Among men, age-matched BMI differences between surveys were smaller for long-term smokers than for nonsmokers. Among women, however, age-matched BMI differences were greater for long-term smokers than for nonsmokers. CONCLUSIONS: In middle-age subjects, longitudinal BMI increases are smaller among smokers than nonsmokers. During old age, the BMI of smokers decreases more than that of nonsmokers. Unknown factors related to gender contribute to larger time period effects of smoking in women than in men.     

Women are more disabled in basic activities of daily living than men only in very advanced ages: a study on disability,morbidity, and mortality from the Kungsholmen Project

OBJECTIVE: We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily living (ADL) functioning in different age groups in the elderly population. METHODS: All 77+-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists, and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria for dementia. The Katz index of ADL was used to measure basic functional status. RESULTS: After adjustment for socio-demographic characteristics, the oldest women (90+ years) had higher disability prevalence and a tendency for higher long-term disability incidence. Women aged 85+ years also had higher morbidity prevalence. Mortality among disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77-84 years). CONCLUSION: We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival with slight disability earlier in adult life.     

Change in lifestyle factors and their influence on health status and all-cause mortality

BACKGROUND: The purpose of this study was to analyse both cross-sectional associations and how longitudinal changes in lifestyle factors from one state in 1980-1981 to another in 1988-1989 influence self-reported health status. Another aim was to estimate the hazard ratios for all-cause mortality for the changes in lifestyle factors and self-reported hypertension during the same period of time. METHOD: The cross-sectional and the longitudinal analyses are based on the same simple random sample of 3,843 adults, aged 25-74, interviewed in 1980-1981 and 1988-1989 and is part of the Swedish Annual Level-of-Living Survey. About 85% of the respondents in the first interview participated in a second interview in 1988-1989. Cross-sectional odds ratios, based on a marginal model, were estimated using the generalized estimating equations. The transitional models were analysed using unconditional logistic regression. A proportional hazard model was applied to investigate the influence of lifestyle transitions on mortality. RESULTS: Physical inactivity, being a current or former smoker and obesity (women only) were strong risk factors for poor health either as main effects and/or combined (interactions). There was a strong interaction between physical activity and smoking, and for women, also between body mass index (BMI) and physical activity. Smoking, physically inactive and obese women had about a ten times higher risk of poor health status than non-smoking, physically active, and normal-weight women. The corresponding risk for men was about five times higher. Physically active, but smoking and obese individuals showed only moderately increased risks for poor health status. The transitional model showed that those who were physically inactive in 1980-1981, but did exercise in 1988-1989, improved their health after adjustments for sociodemographic and other lifestyle factors. Continuing to smoke or being physically inactive or having hypertension at both points in time were all associated with higher hazard ratios for all-cause mortality (1.6, 1.9 and 1.8, respectively) than those who reported that they were in good status at both points in time. CONCLUSIONS: We found that physical activity protects against poor health irrespective of an increased BMI and smoking. The major clinical implications are the long-standing benefits of physical activity and not smoking.     

Correlates of colorectal cancer testing in Massachusetts men and women

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer-related death. Although CRC screening can reduce CRC mortality, it is underutilized. We examined the association between personal and health care characteristics and CRC testing, defined as being current on any test that meets CRC screening guidelines. METHODS: The current investigation relies on questionnaire data from the 1999 Massachusetts Behavioral Risk Factor Surveillance System and a CRC call-back survey of 869 Behavioral Risk Factor Surveillance System participants age 50 and older. Multivariate logistic regression was used to identify predictors of CRC testing. All analyses were stratified by gender. RESULTS: Men were more likely than women to be currently tested for CRC. Physician recommendation for testing was strongly associated with testing among men and women, but among those with a recommendation, men were more likely to be tested than women. Older age, usually having an annual check-up, and HMO membership were associated with CRC testing among men and women. Perceived high risk of CRC was more strongly associated with testing among men, while other cancer screening was more strongly associated with testing among women. CONCLUSIONS: There are important gender differences in the prevalence of CRC testing and in factors associated with testing. Research into understanding gender differences related to compliance with physician recommendations is warranted.     

Gender differences in socioeconomic inequality in mortality

OBJECTIVES: There is uncertainty about whether position in a socioeconomic hierarchy confers different mortality risks on men and women. The objective of this study was to conduct a systematic review of gender differences in socioeconomic inequality in risk of death. METHODS: This research systematically reviewed observational cohort studies describing all cause or cause specific mortality for populations aged 25-64 in developed countries. For inclusion in the review, mortality had to be reported stratified by gender and by one or more measures of socioeconomic status. For all eligible studies, five absolute and six relative measures of the socioeconomic inequality in mortality were computed for male and female populations separately. RESULTS: A total of 136 published papers were reviewed for eligibility, with 58 studies deemed eligible for inclusion. Of these eligible studies, 20 papers published data that permitted the computation of both absolute and relative measures of inequality. Absolute measures of socioeconomic mortality inequality for men and women generally agreed, with about 90% of studies indicating that male mortality was more unequal than female mortality across socioeconomic groups. In contrast, the pattern of relative inequality results across the 20 studies suggested that male and female socioeconomic inequality in mortality was equivalent. CONCLUSIONS: Inferences about gender differences in socioeconomic inequality in mortality are sensitive to the choice of inequality measure. Wider understanding of this methodological issue would improve the clarity of the reporting and synthesis of evidence on the magnitude of health inequalities in populations.