Gender differences in health in later life: the new paradox?

PERGAMON

Social Science & Medicine 48 (1999) 61±76

Gender di€erences in health in later life: the new paradox? Sara Arber *, Helen Cooper Department of Sociology, University of Surrey, Guildford GU2 5XH, UK

Abstract This paper examines gender di€erences in health, based on data from over 14,000 men and women aged 60 and above from 3 years of the British General Household Survey, 1992±1994. There is little di€erence between the sexes in the reporting of self-assessed health and limiting longstanding illness, but older women are substantially more likely to experience functional impairment in mobility and personal self-care than men of the same age. These ®ndings persist after controlling for the di€erential social position of men and women according to their marital status, social class, income and housing tenure. The results reveal a paradox in health reporting among older people; for a given level of disability, women are less likely to assess their health as being poor than men of the same age after accounting for structural factors. Older women's much higher level of functional impairment co-exists with a lack of gender di€erence in self-assessed health. # 1998 Elsevier Science Ltd. All rights reserved. Keywords: General Household Survey; Gender; Disability; Self-assessed health; Paradox; Health inequalities

The well known paradox that men are more likely to die than women, but that women su€er from higher levels of morbidity than men was widely discussed in the 1970 s and 1980 s (Nathanson, 1975, 1977; Waldron, 1976, 1983; Verbrugge, 1979a). However, in recent years the existence of this paradox has been questioned (Macintyre, 1993; Macintyre et al. 1996, this issue; Lahelma and Rahkonen, 1997), with research suggesting that gender di€erences in illhealth are much smaller than the previous orthodoxy suggested. Older people have tended to be neglected in research on gender di€erences in health compared with at other stages of the life course. Similarly, there has been a lack of research on how class intersects with gender and age in later life (Arber and Ginn, 1991, 1995). These omissions are ironic because health needs and the use of health services are greatest among older age groups, and because women outnumber men in later life. There are 50% more women than men in Britain aged 65 and over, and the numerical gender disparity

* Author for correspondence.

increases with advancing age, so that over age 85 there are three times more women than men (ONS, 1996). Therefore, when studying older people it is essential to study gender as a basis of di€erentiation. The aims of this paper are, ®rstly, to examine the extent and nature of gender inequalities in ill-health in later life, focusing on how gender di€erences vary according to the measure of health status used; and secondly, to examine to what extent these gender inequalities can be explained by the di€erential social and structural characteristics of older women and men. Before analysing data on older people using the 1992± 94 General Household Survey, the paper considers the methodological problems associated with researching gender di€erences in health based on samples of older people living in private households.

1. Gender di€erences in health It has become accepted wisdom that `men die and women become disabled'. Women have an expectation of life which is 5±6 years longer than men (Waldron, 1976; ONS, 1996), but have higher morbidity rates.

0277-9536/98/$ - see front matter # 1998 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 9 8 ) 0 0 2 8 9 - 5

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S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

This was discussed by Nathanson (1975) as a `contradiction' which required explanation. She put forward various alternative explanations for this apparent contradiction. Other authors in the US repeatedly demonstrated that ``females have higher rates of illness than males'' (Verbrugge, 1979a, p. 61), and examined reasons for ``the discrepancy between the male excess of mortality and the female excess for some morbidity measures'' (Waldron, 1983, p. 1107). A number of the explanations put forward related to gender roles, for example, that women tend to over-report morbidity more frequently than men, and that women are more predisposed than men to rate their health as poor (Waldron, 1983). Over 10 years after Nathanson's pioneering article was published in 1975, little had changed, Verbrugge and Wingard (1987, p. 111) stated ``regardless of how the questions are worded, women consistently report worse health status than men do'' (emphasis in the original), but this was based on analyses of US data from 1979. The orthodoxy remained extreme, stating ``A cursory look at morbidity and mortality statistics indicates that `females are sicker but males die sooner''' (p. 135). They concluded that ``from a sociomedical viewpoint, females have less healthy lives. They simply do not feel well as often as men do'' (p. 137). Meanwhile, other researchers had moved away from examining gender di€erences in health towards a more explicit focus on di€erences in health among women, but their focus was exclusively on working age women. Early work was cast in a role analytic framework examining to what extent additional roles, such as the parental role and paid employment, had bene®cial or adverse consequences for women's health (e.g. Gove, 1978; Nathanson, 1980; Waldron, 1980; Verbrugge, 1983; Arber et al., 1985). Predating and alongside this strand of work was the growing body of research on inequalities in men's health, stimulated by the publication of the Black Report (Townsend and Davidson, 1982). During the late 1980 s and early 1990 s, feminist researchers began to examine to what extent similar structural factors, associated with social class and material disadvantage, were associated with both women's and men's health (Arber, 1989, 1990, 1991, 1997; Popay et al., 1993; Macran et al., 1994, 1996). Researchers stressed the importance of examining women both in terms of their structural position within society and their family roles, although family roles had little e€ect on men's health (Arber and Lahelma, 1993). This approach, which compared gender di€erences in the nature and extent of inequalities in health, has tended to eclipse the earlier concern with gender di€erences in health. Indeed it has become commonplace to analyse men and women separately, examining gender di€erences in the magnitude of the relationships

between socio-economic characteristics and ill-health. For example, all the articles in the recent Social Science and Medicine special issue on `Inequalities in Health' (Lahelma and Rahkonen, 1997) present data separately for men and women rather than assessing gender di€erences in health. In the quarter of a century since Nathanson (1975) published her seminal article on `the contradiction' between sex di€erences in mortality and morbidity rates there have been far reaching structural changes in women's lives. Major changes in gender roles over that period of time may lead to the expectation that previous sex di€erences in morbidity will also have changed, especially since several of the explanations for the reported sex di€erence in morbidity relate to gender roles. Women have entered the paid labour force in increasing numbers and few women remain full-time housewives for more than a few years when their children are very young (Glover and Arber, 1995; Walby, 1997). Women have gained greater ®nancial independence and more women are bringing up children in a lone parent family (Marsh and Arber, 1993; ONS, 1997). Because of these gender role changes it is unsurprising that the orthodoxy of women being `sicker' than men is increasingly being questioned in the late 1990 s. Recent research has suggested that gender di€erences in health are now much more modest than was hitherto assumed. Macintyre et al. (1996) examined di€erent measures of health using various datasets and found a lack of consistency between health measures in whether there was a female excess in morbidity. In Finland, Lahelma et al. (this issue) used eight measures of health among people aged 25 and over and aged 50 and over. No gender di€erence in self-assessed health was found in either age group, but there was a 20% higher level of disability among women than men over age 50, and a female excess of mental and physical symptoms among those aged over 25. Macintyre et al. (1996) show that gender di€erences in health vary according to stage of the life course, therefore it is necessary to conduct studies of di€erent age groups, rather than assume that the same relationships remain constant throughout the life course. There have been few studies on older age groups, but a US study analysed men and women aged 53 and showed that women had better self-assessed health than men, but women reported higher levels of functional limitation and symptom discomfort than men (Marks, 1996). These ®ndings and those of Lahelma et al. for age 50+ (this issue) suggest the possibility that a new paradox has emerged among older age groupsÐ namely that there is a lack of gender di€erence in selfassessed health but that older women have a higher level of functional disability.

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

However, much research on gender di€erences in health focuses on very broad age groups, e.g. Lahelma et al. (this volume) analyse men and women aged 50 and over, and Verbrugge (1984) analysed broad age groups, such as age 45±64 and age 65 and over. Given the well-known gender di€erences in mortality and that the numerical gender imbalance increases as age advances, it becomes increasingly important to include detailed age controls. The gender di€erence in age composition is evident from the fact that among men and women over 65 in Britain, almost half (49%) of women but only 38% of men are aged 75 and over (ONS, 1996). The renewed interest in gender di€erences in health has largely been divorced from the recent strand of research on structural inequalities in women's health (Bartley et al., 1992; Macran et al., 1994, 1996; Arber, 1996, 1997). Women and men occupy di€erent structural locations within society; there is occupational sex segregation (see Emslie et al., this volume), women are more likely to have low incomes and to be lone parents than men (ONS, 1997). It is therefore essential to marry these two research strands, i.e. to examine gender di€erences in health while also assessing the extent to which gender di€erences can be accounted for by the varying structural characteristics of women and men. Verbrugge (1989) analysed how sex di€erences in over 40 measures of health for adults in Detroit changed when a very wide range of factors were statistically controlled, including role statuses, role satisfaction, lifestyle (smoking, drinking, obesity and physical activity), stress and health attitudes. She found that when all these factors were controlled in multivariate analyses the female excess of illhealth diminished for most health measures and in some cases was reversed (although the resulting male excess was non-signi®cant). However, Verbrugge's paper does not identify which factors were responsible for changes in the sex di€erence. Our analysis will focus on to what extent structural di€erences between older women and men are responsible for gender di€erences in health in later life. The concentration of poverty among women is particularly marked in later life (Arber and Ginn, 1991; Ginn and Arber, 1996), therefore, it is essential to analyse to what extent any gender di€erences in health in later life may be because of the socio-economic disadvantage of older women. Half of older women are widowed, whereas this is the case for under one-®fth of older men (ONS, 1996). Research on marital status and health (e.g. Verbrugge, 1979b; Morgan, 1980; Anson, 1989; Wyke and Ford, 1992; Glaser and Grundy, 1997) has consistently shown that the divorced and separated have poorer health than the married, and single men but not single women report poorer health than the married. The widowed generally

63

have poorer health than those who are married, but this di€erence is less at older ages, and for widows than for widowers. Given the marked gender di€erences in marital status in later life, it is essential to assess whether any gender di€erences in health re¯ect di€erences in marital status between older men and women. 2. Gender and living in residential care Most national health surveys are drawn from samples of residents living in private households and thereby exclude people living in institutions. This is unimportant when analysing the health of people at younger ages, but among the older population is increasingly important with advancing age. It is particularly pertinent when considering gender di€erences in health, because gender is closely associated with entry into residential care. Over twice as many women over 65 (6.4%) as men (3%) lived in a residential establishment at the time of the 1991 Population Census, see base of Table 1 (®gures derived from OPCS, 1993). The gender imbalance had increased since the 1981 Population Census when 4.6% of women and 2.5% of men over 65 lived in a residential establishment (Arber and Ginn, 1991). The 1991 gender imbalance was particularly marked among older age groups with 26% of women compared with 15% of men aged 85+ resident in a communal establishment. Thus, older people interviewed in communitybased samples form an increasingly selected group with advancing age. The relative size and characteristics of this excluded group may change over time as a result of changes in policies relating to residential care. Gender di€erences in residential living do not exist because of gender per se, but because the chances of living in residential care are in¯uenced by social variables such as marital status, which acts as a proxy for the availability of informal carers. Two-thirds of older men are married whereas one-half of older women are widowed (Arber and Ginn, 1991). Older women are thus less likely to have a spouse to provide informal care should they become disabled, increasing their likelihood of entering a residential setting. Table 1 shows that marital status is a much more important determinant of residential living than gender or age. The married are least likely to live in residential care, only 0.9% of married men and 1.2% of married women over age 65, whereas the never married are most likely to live in residential care, 11.7% of single men and 14.4% of single women over 65, see base of Table 1. Although a higher percentage of women than men live in residential care, among the not married under age 85 men are more likely to live in a residen-

64

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76 Table 1 Percentage of elderly women and men resident in communal establishments in 1991, by age and marital status Age

Gender

Married (%)

Widowed (%)

Divorced (%)

Never married (%)

All (%)

65±69

Men Women Men Women Men Women Men Women Men Women Men Women

0.2 0.2 0.5 0.6 1.1 1.5 2.6 4.3 7.0 13.0 0.9 1.2

1.9 1.2 3.0 2.3 5.4 5.0 9.9 11.1 20.4 26.7 7.6 9.0

3.3 1.5 4.6 2.3 7.1 3.9 10.7 7.3 18.3 15.6 5.0 3.2

7.7 5.9 10.1 7.6 13.5 10.6 18.7 16.9 29.3 34.8 11.7 14.4

1.1 1.0 1.6 1.9 3.0 4.3 6.2 10.3 15.2 26.4 3.0 6.4

70±74 75±79 80±84 85+ All 65+

Source: OPCS Census 1991 (1993, Table 2)

tial setting than women in all except one of the age and marital status groups. For example, single men have a higher residence rate than single women in each age group below 85, and previously married men are more likely to be in residential care than previously married women in each age group below 80. Among married people aged 65±74, similarly low percentages of men and women live in a residential setting, but over age 75 married women are more likely to live in residential care than married men, which probably re¯ects the fact that men ®nd it more dicult than women to care for their disabled spouse. Despite the higher level of functional disability of older women than men (which we discuss later), men who are not married are more likely than women of an equivalent age and marital status to live in residential settings. This suggests that older men enter residential care at a lower threshold level of disability than comparable women. The exception is that married men are more likely to remain living within the community than equivalent married women. These complex selection factors at work in relation to entry into residential care are associated with the interaction between gender, marital status and age. They were largely the same in 1981 (Arber and Ginn, 1991) as in 1991, except that the proportion in residential care in 1991 was higher among those aged 80 and over. Since older women are twice as likely as men to live in residential settings, the gender di€erences in health based on community samples will underestimate the disadvantaged health status of older women, because those living in residential care are excluded from study. This reinforces the work of Glaser and Grundy (1997) who used the Sample of Anonymised Records from the 1991 Population Census to compare levels of limit-

ing long-standing illness among older people in private households and living in residential institutions. They show that the health of never married older people based on community samples is relatively better than that of the married, but this is not the case if older people in institutions are included in the analysis. They conclude that ``studies of health . . . in later life may be seriously biased if the institutional population is omitted'' (p. 163). 3. Methodology The paper analyses data from the British General Household Survey (GHS), which is a nationally representative survey interviewing all adults aged 16 and over in about 10,000 private households each year in Great Britain (Bennett et al., 1996). The response rate was about 80% in 1992±94. The paper is primarily based on analyses of men and women aged 60 and over. To produce more robust results for speci®c age groups of older people aged 60 + , we have pooled 3 years of GHS data, for 1992/93 (n = 5130), 1993/4 (n = 5078) and 1994/5 (n = 4736). A special section of questions was asked of people aged 65 and over in 1994/5, which focused on ability to perform a range of activities of daily living, who provides care and use of domiciliary health and welfare services. Our analysis of disability is based on data only from the 1994/5 GHS (n = 2462). Most older people left the labour market a number of years earlier. The time between labour market exit and death is increasing, averaging 17 years for men and 21 years for women. Despite this, we argue that a person's last main occupation during working life pro-

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

vides a good measure of their class position in old age (Arber, 1996). The class of married women has often been measured by their husband's occupation (Goldthorpe, 1983), but this option is only available for a minority of older women, because under two®fths of women over 65 are married. For most older women, the only alternative is to measure class based on their own last occupation. For some of the oldest age group of women this may have been before marriage, over 50 years earlier. However, this is not the case for the majority of young elderly (age 65±74), among whom only 1% never worked, 12% did not return to work after the family formation stage, and nearly half this cohort of young elderly were working in their ®fties (estimated from Dex, 1984). Our earlier research showed strong associations between measuring class based on the individual's own last main occupation and both men's and women's health in later life (Arber and Ginn, 1991, 1993). 4. Gender di€erences in health A commonly used global indicator of ill-health is self-assessed health, which is measured by the GHS question ``Over the last twelve months, would you say that your health has on the whole been good, fairly good or not good?''. Poor self-assessed health has been shown to be a good predictor of mortality in other studies (Mossey and Shapiro, 1982; Idler and Benyamini, 1997). The proportion of older people rating their health as `less than good' rises from about 50% of men and women in their early 60 s to about two-thirds aged 75± 79 and over [see Table 2(a)]. There is a surprisingly

65

small di€erence in the proportion of older men and women who assess their health as `less than good' under age 80. In the early sixties, men are very slightly more likely to report `less than good' health, but there is a slight female excess at ages 65±79 (female to male sex ratios of 1.01±1.03). Above age 80, 70% of women and 63% of men report poor health; about 10% more women than men in their eighties report poor health. Therefore, this measure of health status shows minimal gender di€erences until age 80. We also analysed gender di€erences in limiting longstanding illness [see Table 2(b)]. The GHS asks whether respondents have a `long-standing illness, disability or in®rmity?'. Those who reply `Yes', are asked `Does (it) limit your activities in any way?' Women have an advantage in their sixties with fewer reporting a limiting long-standing illness (LLI), and female to male sex ratios of 0.84±0.86. From age 70 to 84, women are somewhat more likely than men to report LLI, but only above age 85 is there a clear health disadvantage for women, with 17% more reporting LLI. There is a linear increase in the proportion of older women reporting LLI from 32% in their early sixties to 56% in their late eighties, but for men the increase is non linear and is much less sharp, from 37% in the early sixties to 48% in the late eighties. This lack of linearity could re¯ect a higher mortality rate of men than women with LLI, which would con®rm US research (Verbrugge, 1984). The small gender di€erence in self-assessed health and in LLI, as well as the relatively modest changes in health reported with advancing age (shown in Table 2), contrasts markedly with the increase in functional impairment in later life. Older women are more likely than men to su€er from conditions which are non-fatal

Table 2 Gender di€erences in health by age (a) % with Self-assessed health as `less than good'

(b) % with Limiting longstanding illness (LLI)

Age

Men

Women

Sex ratio women/men

Men

Women

Sex ratio women/men

60±64 65±69 70±74 75±79 80±84 85+ All 60+ N= All 65+ N=

51.8 53.6 56.9 65.7 63.1 63.9 56.8 6169 58.5 4573

50.6 54.4 58.7 67.5 69.7 68.6 59.3 8215 61.7 6397

0.98 1.01 1.03 1.03 1.10 1.07 1.04

37.4 41.2 38.2 45.4 47.4 47.9 40.9 6383 42.2 4714

31.6 35.5 42.1 47.5 52.3 56.1 41.5 8450 44.2 6601

0.84 0.86 1.10 1.05 1.10 1.17 1.01

1.05

Source: General Household Survey, 1992/3, 1993/4, 1994/5 (authors' analysis)

1.05

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S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76 Table 3 Gender di€erences in ability to perform activities of daily living by age Age group

(a) % unable to do task Cutting toenails Men Women Walking down road Men Women Going up and down stairs Men Women Bathing, washing all over Men Women (b) % who have diculty or are unable to do task Getting around the house Men Women Getting in and out of bed Men Women Base numbers Men Women

65±69

70±74

75±79

80±84

85+

All 65+

14 17

16 31

25 39

46 60

58 60

23 36

4 9

6 10

8 16

18 23

19 44

8 16

6 5

4 9

5 11

8 16

9 29

5 11

3 5

5 7

6 9

12 15

17 23

6 10

6 6

5 8

7 12

13 11

12 22

7 10

6 7

5 7

6 10

13 8

12 23

7 9

474 558

461 605

238 374

179 228

87 220

1439 2035

Source: General Household Survey, 1994/5

but result in chronic and disabling illnesses hindering their activities of daily living. The 1994 General Household Survey shows that older women are much more likely to experience restrictions of mobility, self-care and ability to perform household tasks than older men. Table 3(a) shows that twice as many older women as men were unable to walk down the road or go up and down stairs. These gender di€erences exist within each age group, e.g. under one-®fth of men over 85 were unable to go out and walk down the road, compared with nearly half of women. Nine percent of men over 85 were unable to go up and downstairs, compared with 29% of women. Also more older women than men were unable to cut their own toenails, especially in their 70 s, and women were more likely to report that they were unable to wash or bathe. The most restricting types of impairments relate to getting around the house and to getting in and out of bed. Table 3(b) shows that women were more likely than men to report these as a diculty or that they were unable to do them, except in the early 80 s when slightly more men than women report such restrictions. We have constructed a scale of the severity of functional impairment by summating responses to the six

questions in Table 3, namely, the reported diculties in getting up and down stairs, walking outside, getting around the house, bathing or washing oneself, cutting toenails and getting in and out of bed. The construction of this scale replicates one used in earlier analyses of the GHS (Arber and Ginn, 1991) in which these six activities of daily living formed a Guttman scale. Each task was scored 0 if the older person could do the task without diculty, scored 1 if they could only do it with diculty, and scored 2 if they could not do it at all or only with help from others. The resulting summated scale has scores ranging from 0 to 12. This scale of functional impairment using the 1994 GHS has a reliability coecient of 0.82 using Cronbach's a, showing that the questions used to create the scale are internally consistent. According to this scale half of older people have no diculty in undertaking any of these six tasks, but this is the case for more older men (56%) than older women (44%) (see Table 4). One-quarter have slight disability (score 1±2), which typically means inability to cut their toenails. Seventeen percent of older women but 12% of men have `moderate' disability (score 3±5), which typically relates to diculty or inability to go up and down stairs and diculty in walking unaided

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76 Table 4 Gender di€erences in functional disability, age 65+ Degree of disability

Men

Women

All, 65+

None Slight (score 1±2) Moderate (score 3±5) Severe (score 6±8) Very severe (score 9±12)

56.2 23.6 11.7 6.3 2.2 100% 1435

44.1 23.8 17.2 9.7 5.2 100% 2027

49.1 23.7 14.9 8.3 4.0 100% 3462

N=

67

the house, which a€ects over twice as many older women (5.2%) in the community as older men (2.2%). Gender di€erences in `severe' disability and in `moderate' or greater disability are shown in Table 5. Seventy-®ve percent more women than men over 65 have `severe' disability. Within each 5 year age group, women are more likely to experience severe disability, with an almost two fold gender di€erence in the late seventies. The gender di€erences in moderate or greater disability [Table 5(b)] are not so extreme, but are evident in each age group. Older people with severe or very severe disability rely mainly on family members or other informal carers to support them in living in the community. Should these sources of assistance not be available, they would either need to receive state-provided domiciliary services or enter residential care. Table 6 shows marked gender di€erences in living arrangements and therefore in sources of informal care for older men and women, which persist throughout the range of disability. Half of older women live alone, compared to one-

Source: General Household Survey, 1994/5 (authors' analysis)

outside. Twelve percent have `severe' disability (score 6+), which typically means that they have diculty washing and are unable to walk down the road unaided. Such a level of impairment would result in older people needing help on an almost daily basis in order to remain living in the community. People with a `very severe' impairment (score 9±12) usually have dif®culty getting in and out of bed and moving around

Table 5 Gender di€erences in (a) severe and (b) moderate or greater disability by age (a) % with severe disability (score of 6+)

(b) % with moderate or greater disability (score of 3+)

Age

Men

Women

Sex ratio women/men

Men

Women

Sex ratio women/men

65±69 70±74 75±79 80±84 85+ All 65+ N=

6.0 5.0 8.4 17.3 22.3 8.5 1435

7.7 9.2 16.3 20.2 39.7 14.9 2027

1.28 1.84 1.94 1.17 1.78 1.75

13.8 14.0 22.7 38.5 45.8 20.2 1435

16.5 25.5 34.4 47.9 66.2 32.1 2027

1.20 1.82 1.52 1.24 1.45 1.59

Table 6 Household living arrangements by degree of disability, men and women aged 65+ Men

Women

Degree of disability

Lives alone

With spouse

With others

100% N=

Lives alone

With spouse

With others

100% N=

None Slight Moderate Severe Very severe All, 65+

21 25 37 27 22 24

64 61 48 63 62 61

15 14 15 10 16 15

(806) (338) (168) (91) (32) 1435

43 52 58 60 40 49

43 34 25 20 33 35

14 14 17 20 27 16

(894) (482) (349) (196) (106) 2027

Source: General Household Survey, 1994/5

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S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

Fig. 1. Percentage reporting good health by social class by age. Source: General Household Survey, 1992/3, 1993/4, 1994/5 (author's analysis).

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

quarter of older men. Solo living is higher for women with a moderate or severe level of disability (60%), suggesting that these disabled older women are reliant on relatives and friends living elsewhere and on state services. Even among women with very severe disability, most of whom are housebound, 40% live alone. Other women with an equivalent level of disability will have moved to live with others; 27% live with someone other than their spouse, which is the living arrangement of only 14% of non-disabled older women. Older men's living arrangements vary little according to their level of disability. Over 60% of older men live with their spouse across all disability levels, except for those with moderate disability, where this falls to 48%. Thus, older disabled men usually have a spouse to provide care should they need it, and are less likely to have to rely on others living elsewhere or to have to enter residential care. Older men are therefore more likely to remain living in private households for longer, rather than enter residential care with a given level of functional disability. If di€erential selection into residential settings associated with marital status did not occur, the gender di€erences in disability shown in Tables 3±5 would be even greater. Thus, older women's disadvantage in terms of their higher level of disability based on community samples would be even greater if older people in residential settings were also included in analyses. This section has highlighted the existence of a `new paradox' among older people in Britain. Namely that there is very little gender di€erence in self-assessed health or limiting long-standing illness among older people, especially those under age 80, but at the same time this lack of gender di€erence co-exists with older women being about 75% more likely to experience severe disability than older men. Although earlier literature suggested that one reason for the higher reported morbidity rate of women was that women were more likely to over-report symptoms than men, the GHS data for older people points to the reverse, namely that given older women's higher level of functional disability, they are less likely than would be expected to report poor health. This supports Macintyre et al.'s ®ndings (in this volume) that women are less likely to report limiting long-standing illness with a given level of symptoms than is the case for men. Before looking more closely at gender di€erences in health using multi-variate analyses, we examine class inequalities in health for older men and women. 5. Class inequalities in health among men and women Despite the very modest gender di€erences in selfassessed health in later life [shown in Table 2(a)], the

69

health di€erences according to class based on last main occupation are very striking across the full age range of older men and women (see Fig. 1). In each 5 year age group under 80, about 30% more men previously in a professional occupation rate their health as `good' than men previously in a semi- or unskilled occupation. Even among men in their 80 s, 20% more professional men report their health as `good'. Class di€erences are so strong and consistent that di€erences in self-assessed health by age are much less important than di€erences by class; e.g. fewer men who previously worked in manual occupations in their 60 s rate their health as `good' than professional men 20 years their senior. The class di€erences based on previous occupation in working life for men occur for each age group, including in their late eighties. For older women, class di€erences in self-assessed health are also linear and consistent across the age range. They are somewhat weaker among women in their 60 s; about 20% more women previously in professional occupations rate their health as `good' than women in semi- and unskilled occupations. Among women in their 80 s, the class di€erences based on the woman's previous occupation are greater, with only 25% of women previously in a manual occupation rating their health as `good' compared to 56% of women previously in professional occupations. For both older men and women, the class di€erences in self-assessed health are similar but slightly stronger in 1992±94, than in our earlier research using 1985±87 GHS data (Arber and Ginn, 1991, 1993). These very strong and consistent class di€erences in self-assessed health are particularly noteworthy given possible problems associated with measuring class based on the older person's last main occupation, which for men in their 80 s is likely to be up to 20 years earlier, and for the current generation of older women may be based on their occupation thirty or more years earlier. This indicates the resilience of class during working life in in¯uencing health throughout the life course, including in very old age. Class di€erences in survival mean one would expect a reduction in class inequalities in health with advancing age, but there is no evidence that this occurs, at least up to the age of 85 years. Class inequalities in functional disability are also evident among older people (see Fig. 2). However, they are less clearcut than for self-assessed health, partly because data is only available for a single year, 1994/5, which means there are smaller numbers in each class and age group resulting in less reliable ®gures. Nevertheless, Fig. 2 shows a generally linear gradient in the proportion of the population with moderate or greater disability for each age group from 65 up to age 80 and over. For example, men in their 70 s who were previously in professional or managerial occupations

70

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

are half as likely to have a moderate or greater functional impairment than men previously in semi- or unskilled occupations, varying from 8% to 22% of men aged 70±74. For women the class gradients are

somewhat weaker. They are not present for women in their late 60 s, but are for women in their 70 s and 80 s, for example, in the early 70 s, 18% of women previously in professional and managerial jobs are dis-

Fig. 2. Percentage with moderate or greater disability by age and social class. Source: General Household Survey, 1994/5.

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

abled compared with nearly twice as many women (32%) previously in semi- or unskilled jobs. These class gradients in disability are somewhat stronger than in the 1985 GHS (Arber and Ginn, 1991, 1993). Health inequalities relating to other measures of socio-economic status show consistent ®ndings. For example, older men and women living in Local Authority housing have poorer health than those living in owner occupied housing in each age group for both self-assessed health and functional impairment. 6. Gender di€erences in health: multivariate analyses This section uses logistic regression analysis to examine how gender di€erences in self-assessed health and in `severe' disability change when social and structural characteristics of older men and women are included in the same analysis. One aim of this section is to assess whether gender di€erences in health can be explained by older women's more disadvantaged social and economic circumstances. Model 1 gives the odds ratio for `less than good' health for women with men as the reference category (1.00). Among people aged 65 and over, the odds ratio for reporting `less than good' health is 17% higher for women than men (Table 7), whereas the odds ratio of severe disability is 84% higher for women than for men (see Table 8). The gender di€erences are statistically signi®cant (P < 0.05 for self-assessed health and P < 0.01 for disability, shown by asterisks against the odds ratios in Tables 7 and 8). The relative magnitude of the gender di€erence contrasting these two measures is evidence of a new paradox of a relatively small gender di€erence in self-assessed health but a large gender di€erence in functional impairment. The second aim of this section is to compare the series of models for selfassessed health (Table 7) and disability (Table 8) in order to throw more light on this `new paradox'. Model 2 includes age in 5 year age groups, which reduces the gender di€erence in self-assessed health from an odds ratio of 1.17 to 1.12 for women (a no longer statistically signi®cant gender di€erence). This change in odds ratio indicates that part of the female excess in poor self-assessed health is because women are on average older than men. The female excess of severe disability is reduced to an even greater extent by the inclusion of age in Model 2 (Table 8), from an odds ratio of 1.84 to 1.61, showing that the greater average age of older women is partly responsible for the gender di€erence in level of disability. Despite large variations in marital status between older women and men, inclusion of marital status in Model 3, does not diminish the gender di€erence in either self-assessed health (Table 7) or functional disability (Table 8). Marital status does not have a stat-

71

istically signi®cant e€ect on either of these health variables. The odds ratios for the married and widowed are equivalent, but for the divorced are higher on both health measures, although they do not reach statistical signi®cance. Sex segregation in the labour market means that older women were more likely to have previously worked in lower status occupations than men. As shown in Figs. 1 and 2, there is a strong association between an older person's social class and both measures of health status. When social class is included in Model 4, the gender di€erence in self-assessed health disappears entirely, reaching parity in the odds ratios for men and women (Table 7). As expected, social class has a statistically signi®cant e€ect on health, with people previously in semi-skilled and unskilled occupations having an odds ratio of poor self-assessed health which is two and a half times greater than for people previously in professional or managerial occupations. Those who had `never worked' are also more likely to report poor health. The reduction in the gender di€erence in severe disability with the addition of class to the model (Model 4, Table 8) is also substantial, from an odds ratio for women of 1.60 to 1.41 after including social class in the model. This shows that part of the reason for the higher levels of functional impairment among older women relates to their more disadvantaged labour market position during working life. Income is strongly associated with self-assessed health (Table 7, Model 5). Income has been measured as household income in quintiles, after equivalising for the number of adults in the household. Older people with the highest quintile of income (the reference category) report the best health. Those in the lowest two quintiles, most of whom will be solely dependent on the state pension, have a 60% higher odds ratio of reporting poor health compared with those in the top income quintile, after including social class and housing tenure in the model. Housing tenure is also signi®cantly associated with an older person's self-assessed health. Older people living in Local Authority housing have about twice the odds ratio of reporting poor health compared with owner occupiers. It was expected that any housing tenure di€erence could partly re¯ect reverse causation, e.g. if older people had moved to Local Authority sheltered housing because of increased disability. The two main housing tenures were therefore subdivided according to whether the older person had moved in the last 5 years. We found little evidence of reverse causation; there is little di€erence in the self-assessed health of older people who have been in their owner occupied accommodation for varying lengths of time. Although, there is a somewhat higher odds ratio of 2.08 for people who moved to Local Authority accom-

72

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76 Table 7 Odds ratios for logistic regression of self-reported health as `less than good', aged 65+

Sex Men Women Age group 65±69 70±74 75±79 80±84 85+ Marital status Married Widowed Single Divorced/separated Social class Professional/managerial Clerical, lower non-manual Skilled manual Semi-skilled & unskilled Never worked Household income Top 20% 60 < 80% 40 < 60% 20 < 40% Lowest 20% Length of time in current housing tenure Owner 5+ years Owner <5 years Private renter Local Authority <5 years Local Authority 5+ years Degree of disability None Slight (score 1±2) Moderate (score 3±5) Severe (score 6±8) Very severe (score 9±12) Model improvement DLLR Change, degrees of freedom N=

Model 1

Model 2

Model 3

Model 4

Model 5

Model 6

+ 1.00 1.17*

ns 1.00 1.12 +++ 1.00 1.13 1.56** 1.86** 1.89**

ns 1.00 1.11 +++ 1.00 1.14 1.56** 1.86** 1.87** ns 1.00 1.03 1.33 1.33

ns 1.00 1.01 +++ 1.00 1.12 1.54** 1.92** 1.90** ns 1.00 0.97 1.38* 1.22 +++ 1.00 1.40** 1.77** 2.49** 2.68**

ns 1.00 1.00 +++ 1.00 1.07 1.49** 1.81** 1.81** ns 1.00 0.93 1.28 1.03 +++ 1.00 1.29* 1.41** 1.88** 2.38** ++ 1.00 1.35* 1.33* 1.61** 1.55** +++ 1.00 0.89 0.80 2.08** 1.70**

ns

4.4 1 2951

41.2 4

5.0 3

80.8 4

72.3 8

ns

1.00 0.85

1.00 0.94 1.12 0.95 0.66* + 1.00 0.87 1.43* 0.95 ++ 1.00 1.30* 1.35* 1.65** 1.92*

1.00 1.21 1.15 1.62** 1.63** +++ 1.00 0.82 0.69* 1.46 1.42** +++ 1.00 2.40** 7.75** 14.2** 24.6** 400.7 4

Statistical signi®cance of variable in the model, +p < 0.05; + + p < 0.01; + + + p < 0.001. Statistical signi®cance of di€erence from the reference category, *p < 0.05; **p < 0.01. Source: General Household Survey, 1994/5.

modation in the last 5 years, than the odds ratio of 1.70 for people who had lived in their Local Authority property for more than 5 years. Despite the strong association between self-assessed health and both income and housing tenure, the gender di€erence in self-assessed health does not change with the inclusion of income and housing tenure in the model. However, for severe disability, the gender

di€erence becomes more marked with the inclusion of income and housing tenure in the model (Model 5, Table 8), rising from an odds ratio for women of 1.41 to 1.53. The pattern of the relationship with housing tenure and disability is as expected, with a three times higher odds ratio of severe disability for older people who had lived in their Local Authority accommodation for under 5 years, and an odds ratio of two for

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

those living in Local Authority tenure for more than 5 years, compared with the reference category of living in owner occupied accommodation for over 5 years. This is consistent with both disability leading to a move to Local Authority accommodation and with the greater health disadvantage of living in public housing in Britain. The association between household income and `severe' disability was not as expected (Model 5, Table 8). After controlling for social class and housing tenure, the lowest odds ratio of severe disability occurred for older people in the lower 40% of the income distribution, mainly those living solely on a

73

state pension. Higher levels of disability were reported by those in the middle of the income distribution. This ®nding could be attributed to the changes resulting from the 1990 Community Care Act, and the restriction of Local Authority ®nancing of residential care to those eligible for means-tested Income Support (mainly older people in the lowest 40% of the income distribution). As a consequence, in 1994 it would have been easier for an older person on a very low income (with a given level of disability) to enter residential care, than for someone on an average or above average income. Those in the highest quintile of the income distribution are more likely to have sucient ®nancial

Table 8 Odds ratios for logistic regression of severe disability for men and women aged 65+

Sex Men Women Age group 65±69 70±74 75±79 80±84 85+ Marital status Married Widowed Single Divorced/separated Social class Professional/managerial Clerical, lower non-manual Skilled manual Semi-skilled & unskilled Never worked Household income Top 20% 60 < 80% 40 < 60% 20 < 40% Lowest 20% Length of time in current housing tenure Owner 5+ years Owner <5 years Private renter Local Authority <5 years Local Authority 5+ years Model improvement DLLR Change, degrees of freedom N=

Model 1

Model 2

Model 3

Model 4

Model 5

+++ 1.00 1.84**

+++ 1.00 1.61** +++ 1.00 1.16 1.83** 2.97** 6.83**

+++ 1.00 1.60** +++ 1.00 1.16 1.85** 2.98** 6.96** ns 1.00 1.01 0.91 1.38

+ 1.00 1.41* +++ 1.00 1.15 1.84** 3.02** 7.16** ns 1.00 0.97 1.00 1.32 +++ 1.00 1.19 1.33 2.30** 2.60**

26.0 1 2956

135.3 4

1.3 3

34.6 4

++ 1.00 1.53** +++ 1.00 1.21 2.02** 3.35** 8.85** ns 1.00 0.93 0.88 1.25 +++ 1.00 1.16 1.24 2.08** 2.77** +++ 1.00 1.63* 1.68* 0.58* 0.56* +++ 1.00 1.31 1.27 3.14** 2.01** 90.9 8

Statistical signi®cance of variable in the model, +p < 0.05; + + p < 0.01; + + + p < 0.001. Statistical signi®cance of di€erence from the reference category, *p < 0.05; **p < 0.01. Source: General Household Survey, 1994/5

74

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

resources to pay for private residential care, and thus their odds ratio of `severe' disability is somewhat lower than for older people with a middle level income, but is higher than for the 40% on the lowest income. Since older women are more likely to be at the lowest levels of the income distribution, they may ®nd it easier to enter residential care under the present ®nancial arrangements, and therefore the gender di€erence in disability becomes somewhat greater when income and housing tenure are included in Model 5. This ®nding of the relationship between income and disability di€ers from our ®ndings based on the 1985 GHS, when there was no statistically signi®cant relationship between income and disability (after including class and age in the model) (Arber and Ginn, 1991, 1993). However, the linear relationship between having a high income and good self-assessed health remained strong and consistent in both 1985 and 1994. The di€erence in the relationship between income and disability in 1994 (compared to 1985), lends support to our interpretation that policy changes relating to the availability of public funding for entry into residential care may be responsible for this di€erence over time. When the level of disability of the older person is included in the model to predict self-assessed health (Model 6, Table 7), the gender di€erence reverses, so that older women have a lower odds ratio of reporting poor health (0.85) than men. The degree of disability of an older person has a strong e€ect on self-assessed health, the odds ratio rises to 7.7 for those with moderate disability, 14.2 for those with `severe' disability and 24.6 for those with `very severe' disability compared with the reference category of no disability. Because older women are more likely than older men to have a severe disability, the result of including degree of disability in the model means that for a given level of disability, an older woman is less likely to report poor health than an older man. In addition, the e€ect of age on self-assessed health becomes nonsigni®cant once degree of disability is included in the model. However the oldest age group, over age 85, report that their health is somewhat better than that of other age groups, after controlling for degree of disability. Including degree of disability in the model does not a€ect the nature of the relationship between social class or income and self-assessed health, but does weaken the relationship between housing tenure and health, which supports the argument that part of the association between poor self-assessed health and moving to Local Authority residence in the previous 5 years is because of disability. In summary, the original gender di€erence in selfassessed health in which older women are more likely to report poor self-assessed health is mainly because of their older age on average than men, and because they occupied lower positions than men in the class struc-

ture during their working life. When older women's greater likelihood of experiencing functional disabilities is included in the model, this results in a reversal of the gender di€erence, so that older women are shown to be less likely to report poor health than older men. This represents a `new paradox' which needs explanation, namely why, after controlling for age, class and income, older women with a given level of functional impairment are more likely to report good health than older men. 7. Conclusion This paper has examined gender di€erences in health among older people in Britain in the mid-1990 s, focusing on self-assessed health, and the likelihood of experiencing functional impairments that adversely a€ect activities of daily living. Our research shows that minimal gender di€erences in self-assessed health coexist alongside substantial gender di€erences in disability, representing a new paradox. Older women are disadvantaged compared to older men both because of their greater level of severe disability and their living arrangements. Older disabled men usually have a spouse to provide care should they need it, and are less likely to have to rely on others living elsewhere or to enter residential settings. This contrasts with the 60% of older women with moderate or severe disability who live alone, and are therefore reliant on family members or friends and neighbours to remain living in the community. Should these sources of assistance be unavailable, they would either need to receive state or voluntary sector care services or enter residential care. The analyses in this paper use the General Household Survey, which excludes people living in residential settings. The likelihood of entering residential care is greater for the never married, divorced and widowed than for the married, and among the non married under age 80 men are more likely to live in residential settings than women. Our multivariate analysis suggests that income may also be a selection factor relating to entry into residential care, with older people who only have a state pension (the lower 40% of the income distribution) being more likely to enter residential care than those on middle incomes. These selection factors mean than gender di€erences in disability are likely to be even greater if older people in residential care were included in research studies. We would expect older women to report poorer health than older men, because older women are more likely to be socially and materially disadvantaged than older men. Class based on occupation during working life is strongly related to self-assessed health and disability for both older women and men. On average,

S. Arber, H. Cooper / Social Science & Medicine 48 (1999) 61±76

women are older than men, they are more likely to be widowed, to have worked in lower social class occupations and to be in the lower two quintiles of the income distribution. Class based on occupation during working life is strongly related to self-assessed health and disability for both older women and men. Any assessment of gender di€erences needs to take the various aspects of older women's social and economic disadvantage into account. When this is done, there is no gender di€erence in self-assessed health, but the disadvantage of older women in terms of functional disability remains substantial. Women's self-assessed health is shown to be better than men's once we also take into consideration the greater likelihood that older women experience functional impairments. This research supports the ®nding of other studies that there is little gender di€erence in self-assessed health among older people in the mid-1990s. However, the `new paradox' that older women have a more positive self-assessment of their health status than men, once age, class, income and their greater level of functional disability are taken into account, requires further explanation.

Acknowledgements We are to grateful to the Oce of National Statistics for permission to use data from the General Household Survey, and to the Data Archive and Manchester Computing Centre for access to the data. We would like to thank the Health Education Authority for funding research on which parts of this paper are based. We particularly appreciate the helpful comments of Jay Ginn on an earlier version of this paper and those of the anonymous referees.

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