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Older adults' self‐rated health and differences by age and gender: A quantitative study

Background: The older adult population is expected to grow, presenting potential challenges for individuals and society. Maintenance of older adults' health will be an important factor for healthy aging. It will also be a challenge for health professionals who work to promote health and care equity. To promote healthy aging and equal care, an overview of older adults' self‐rated health is needed. The aim of this study was to describe selfrated health among older adults' living at home describe age group and gender‐based health differences. Methods: A descriptive and a comparative cross‐sectional study. The questionnaire study was part of a Swedish national population study. Randomly selected older adults 65‐84 years living in five counties in central Sweden. The response rates were 79% and 75% for those 65‐79 years and 80‐84 years, respectively. Participants (n = 13922) were divided into two age groups: 65‐79 years (n = 5926 male, n = 5755 female) and 80‐84 years (n = 1208 male, n = 1033 female). Results: Older adults generally self‐rated their health as good, especially in the age group aged 65‐79 years. Females self‐rated their health as poorer than males, especially among those aged 65‐79 years. Gender‐based health differences decreased in those aged 80‐84 years. Conclusions: It is important to address these gender‐based health differences; health policies and programmes are needed that promote equitable healthy aging.


Introduction
It is estimated that by 2050 the global population of those 60 years or older will reach 21% [1]. Sweden and Italy have Europe's largest population proportions of older adults. In Sweden, 1.7 million (18%) of the population is 65 years or older [2]. The average lifespan in Sweden is 79 and 83 years for males and females, respectively. In 2060, the number of older adults in Sweden is expected to be 2.7 million [1]. Most forecasts predict an increased number of older adults in the Western world [3]. However, there is no accurate prediction of what proportion of adult life years will be healthy.
Average life expectancy continues to rise in Sweden, primarily as a result of the significant decrease in mortality rates for cardiovascular diseases, and more so among men than women [4]. Women live longer than men. Cancer is a relatively more common cause of death, despite mortality due to cancer decreasing over time. Stroke has decreased among women and men over the age of 65. The incidence of myocardial infarction has also declined mostly among people above retirement age. However, some health differences remain or are increasing. There are health differences between groups with different educational backgrounds. All the major causes of death in the population, such as cardiovascular disease, stroke, cancer, accidents, suicide and alcohol-related illnesses are more common among those with less education [4].
Healthy aging is also influenced by a variety of interacting determinants, including lifestyle and living conditions, social networking, socio-economic status, educational background and living environment [5,6,7]. Older adults' health is related to their ability to adapt to and compensate for their disabilities [8]. Their health experience has been described in terms of autonomy, togetherness, security and peace of mind. There are major differences in older adults' health due to socio-economic status [6,9]. There have also been reports of gender differences in self-rated health, with females rating their health as worse than males [5,10].
Healthy aging is a process in which the body slows down physically and cognitively and simultaneously adapts while autonomy and self-determination are maintained [7]. The most widely recognized definition of health is by the World Health Organization [11], which describes health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. This has replaced the biomedical description of health as the absence of disease. Another accepted definition of health is its relation to whether a person experiences a sense of coherence (SOC), consisting of the components of comprehensibility, manageability and meaningfulness [7,12]. Antonovsky [12] described the state of health on a continuum with individuals moving between two opposing poles: complete ill health and full health. Throughout life, individuals move between these states of feeling better and worse.
The expected increase in the older adult population poses a health care challenge [5]. Forecasts indicate that the cost of elderly care in Sweden may increase by 270% by the year 2040. One challenge is that older adults report more health complaints compared with health professionals' needs assessments [13]. Health, health promotion and equal treatment are key factors promoting healthy aging [5,13). Therefore, this study aimed to describe self-rated health among older adults living at home along with any age and gender-based health differences.

Research design and ethics
This was a descriptive, questionnaire-based crosssectional study [14]. It formed part of a larger population-based survey, Life & Health, in Sweden [15] that aims to study health trends across the population and older adults' self-perception of their health, as well as life habits and living conditions.
The study followed the ethical principles for human research of the Declaration of Helsinki [16] and Swedish Research Council [17] in relation to informed consent, confidentiality and study procedures. The participants received information about the study aims and processes before giving their informed consent to participate. They had the option of withdrawing at any time without giving a reason. All data was treated as confidential, kept inaccessible to unauthorized persons and used solely for study purposes. Participants' responses were anonymised.

Sample and data collection
Statistics Sweden, the Swedish Government Agency responsible for Swedish official statistics, developed a random sample from the population register in Sweden. In total, 13,922 older adults aged 65-84 years and living in five counties in central Sweden participated. The only exclusion criterion was if the person lived in a nursing home.
The questionnaire was developed by researchers and statisticians from the five counties where the study was performed [15]. Areas investigated included background characteristics such as age, gender, education and housing, as well as health, living conditions and need for additional care. In the present analyses, we included background and health measures. The questions were presented with response categories, the majority of which were nominal or ordinal scales with the option of providing additional comments at the end of the questionnaire [18].
The questionnaires were disseminated in sealed envelopes with a postage-paid return envelope. The sealed envelope included an introduction explaining the study aim, that participation was voluntary, that data would be kept confidential and that participants' identity was protected. Three reminders were sent, as needed. The response rate was 79% among those aged 65-79 years and 75% among those 80-84 years.

Data analysis
Data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows version 19.0 (SPSS Inc., Chicago, IL, USA). Nominal data are presented as absolute frequency (number = n) and relative frequency (%) [18]. Non-parametric tests included the chi-square test to examine health differences between genders and the Mann-Whitney U to examine differences between the two age groups, namely, 65-79 years and 80-84 years. The median was used to describe the central tendency and minmax was used to describe variance. To avoid type I error, only p-values < .01 were considered statistically significant. Missing data are presented because these made up less than 1% and data were neither replaced nor imputed [18].

Results
The results describe 13,922 self-rated health assessments of older adults living at home with health differences by gender and age groups 65-79 years (n = 5,926 males, n = 5,755 females) and 80-84 years (n = 1,208 males, n = 1,033 females). The characteristics and general health, long-term diseases or health problems, short-term problems or symptoms, mental health and dental health are described.

General health
Overall, participants aged 65-79 years rated their general health as good (Table 1); those aged 80-84 rated their health as neither good nor poor. Statistically significant gender differences were found on the health assessment with a greater proportion of males than females estimating their health as good or very good. Regardless of age group, participants could handle their daily activities well but were troubled by moderate pain. More females than males were bothered by anxiety and or depression (Table 1). These differences were statistically significant.

Long-term diseases and problems
More than a third of participants aged 65-79 years had had long-term diseases or problems for longer than six months (males: yes 38%, no 62%; females: yes 38%, no 62%). Among participants aged 80-84 years, the proportion of both males and females who had had long-term diseases or problems was greater (males: yes 43%, no 57%; females: yes 47%, no 53%). Table 2 shows participants' descriptions of long-term diseases or problems during the last year.

Short-term problems or symptoms
Both males and females reported having been occasionally bothered by musculoskeletal pain (Table  3). Females reported being troubled more by shortterm diseases or problems compared with males. A larger proportion of females reported more problems than males, including sleep problems and fatigue during the last three months. These differences were statistically significant (Table 3).

Mental health
Females aged 65-79 years reported worse mental health on several variables compared with males' ratings (Table 4). Females aged 65-79 years reported a lower sense of coherence (SOC) than did males [11]. These differences were statistically significant (Table  4).
More than half of females aged 80-84 years had very good or good dental health (very good 14%, good 48%, neither good nor poor 29%, poor 8%, very poor 2%). .000 a 1 = never, 2 = occasionally, 3 = on several occasions, 4 = almost all the time .227 a 1 = better than usual, 2 = as usual, 3 = less than usual, 4 = much worse than usual b 1 = not at all, 2 = no more than usual, 3 = more than usual, 4 = much more than usual c 1 = very optimistic, 2 = fairly optimistic, 3 = neither optimistic nor pessimistic, 4 = quite pessimistic, 5 = very pessimistic d Low SOC = ≥ 59 points, high SOC = ≥ 75 points, max SOC = 91 points (SOC = experiences a sense of coherence [6,11] Compared with males, females aged 65-79 years had more problems with sensitive teeth and teeth grinding ( Table 5). Males in the same age group were troubled more by caries than were females. Females aged 80-84 years were bothered more than were males by sensitive teeth necks. The differences were statistically significant (Table 5).

Method discussion
The primary strength of the study was its large and randomly selected sample, which enables generalization to the wider population [14]. Another strength was the high response rate and a low amount of missing data. According to Vuorisalmi et al. [19], self-rated health has been recognized as a valid and reliable measure of health among older adults. The World Health Organization [11] has recommended this indictor to verify health in population-based studies of older adults. However, it may have been preferable to divide the group aged 65-79 years into two groups, because factors may differ for a 65-yearold (the normal retirement age in Sweden) compared to a 79-year-old, which may have influenced the selfrated health measures. However, this study followed the age groupings used in national population surveys in Sweden, allowing comparisons between counties and various measurements over time. This study has an important value and is relevant to health care policy and clinical care. Use of questionnaires in which participants use response categories may have limitations but this applies to most questionnaires. However, participants were given an opportunity to comment with free text at the end of the questionnaire.

General health
The majority of participants aged 65-79 years rated their general health as good, which decreased to neither good nor poor for those aged 80-84 years. Marques et al. [20] studied older adults' subjective health, social status and age identification across different countries. Their study demonstrated that subjective health was stronger in countries where older adults' social status was perceived as being higher, such as Sweden, the other Nordic countries, Switzerland, Great Britain, Belgium and Germany.
The majority of participants aged 65-79 years stated that they had no problems with movement, though there were significant health differences between genders in both age groups. A larger proportion of females than males stated that they had some difficulty with movement. Yong et al. [22] showed gender differences in poorer walking and position transitions among females 75 years and older. In the current study, few participants aged 65-79 years needed help with their daily hygiene but the rate increased for both males and females aged 80-84 years. Regardless of age group, a large proportion of participants reported that they could handle their daily activities. This compares favourably with the findings of Thorslund and Parker [3] who showed that regardless of methodological differences or statistical representativeness, older adults' ability to manage activities of daily living has improved, while at the same time a greater proportion of older adults have specific health problems [3].
The majority of males and females in both age groups reported experiencing moderate pain or discomfort. There were significant gender differences, with more females than males reporting moderate to severe problems with pain. Although the definition of pain may differ according to the study [23], chronic pain has been shown to increase with age [24). The prevalence of chronic pain among older adults has been reported to vary from 50% (25) to 83% (26).
Older adults with pain are more likely to rate their health as poor (27). However, as Collies and Waterfield [23] noted, there is a distinction between having pain and having a problem with pain.
Karlsson [13] showed that compared with older adults' self-reporting, health professionals tended to rate their patient as having less pain. According to Josefsson [28], there is a great deal of ignorance about pain among older adults. Pain may be existential, meaning it is a social or spiritual form that may manifest itself in emotions such as anxiety, fatigue or sadness. It is important that health professionals can appreciate whether their patient is experiencing existential pain, so they can determine the correct course of action.
Our results show significant health differences in anxiety and / or depression between males and females. More females than males rated that they felt anxiety or depression. These feelings may be related to females experiencing more pain and discomfort, which can lead to poorer self-rated health. According to Tai-Seale et al. [29], little time is spent on older adults' mental health in primary care. Resources should be available in primary care to promote mental health, given an aging population [1] and that a large proportion of older adults have problems with anxiety or depression. Peace of mind is reported to be a main factor in older adults' experience of their health [8].

Diseases and problems
Among participants aged 65-79 years, one in three men and women reported having long-term diseases or problems lasting longer than six months. This proportion increased with age, especially among females, among whom almost half of those aged 80-84 years reported chronic diseases or problems. Josefsson [28] reported that a person's age is strongly associated with disease. However, although age changes are often due to normal aging, they may lead to increased sensitivity. The reduction in older adults' reserves can mean they have a reduced resistance to diseases and environmental stresses. This may be one reason why old age leads to increased risk for diseases or problems.
The most common long-term diseases and symptoms during the past year reported by males were cardiovascular disease, hypertension, tinnitus, hearing loss and physical disabilities. Compared with males, females aged 65-79 years reported more chronic diseases. Both males and females reported hearing loss, which, according to Josefsson [28] is the most common disorder among older adults. Hearing loss is a natural aging process of the inner ear. From [7] showed that older adults' health was related to their ability to adapt to and compensate for their disabilities. Thus, it is essential that older adults and their health professionals know the differences between natural and pathological age-related changes, to allow correct assessment and action.
There were also significant differences between males and females on short-term problems or symptoms during previous three months. More than one in three females were plagued by pain in their shoulders, neck, back or hips occasionally or almost all the time, compared with males among whom one in four had the same problems. Compared with males, females had more problems with sleep, fatigue and weakness, anxiety and worry during the previous three months. Borglin et al. [30] suggested that females who rated their health as worse had a greater problem with decrease in power and mobility, as suggested by their low physical activity. Older adults with an unaddressed decrease in power and mobility may end up in a vicious circle; they may be too tired to cope with daily life and thus move less, which leads to stiffer joints and even more immobility.

Mental health
There were significant mental health differences between males and females. A larger proportion of females than males aged 65-79 years reported that they had trouble sleeping due to anxiety, feeling tense, not managing their problems, feeling dejected and depressed, and losing faith in themselves. This is consistent with Yong et al. [22], who reported poorer mental health among older females compared with males. The prevalence of mental diseases among older adults is common and increasing rapidly [29].
Because the global population is aging rapidly [1], good geriatric care is critical, including older adults' mental health and gender differences. However, little time is spent on mental health care for older adults [29].
More than half the participants aged 65-79 years had a very or fairly optimistic view of their own future. There was a significant gender difference in sense of coherence (SOC) with more males than females aged 65-79 years reporting a high SOC. It is positive that participants reported a high SOC, given the connection between experienced health and wellbeing [12]. However, females had a lower SOC than males. It is therefore particularly important to promote a sense of coherence among females by having them take advantage of their resources, strengths and abilities [7,12].

Dental health
Seven out of 10 older adults aged 65-79 years reported good or very good dental health and six out of 10 aged 80-84 years reported having good or very good dental health. Participants' common dental problems were caries and sensitive teeth. There were significant gender differences in the group aged 65-79 years, with more males reporting caries and more females reporting trouble with sensitive teeth and teeth grinding. However, these older adults' dental health was good compared with the study by Morales-Suarez-Varela et al. [31] who reported that a large proportion of their sample had trouble with dental health. Andersson et al. [6] note that there is little knowledge in primary care about how dental health affects older adults' well-being. Dental health and well-being-associated primary care should pay greater attention to older adults' dental health rather than leaving dental care to dentistry. Because no one agency can tackle all issues, the promotion of healthy aging requires a multi-agency response.

Conclusions
Most participants aged 65-79 years rated their general health as good, while health ratings decreased in the group aged 80-84 years. Females reported a lower sense of coherence than did males. Females rated their physical and mental health worse than did males, which was clearer in the group aged 65-79 years. Gender differences tended to level off in the group aged 80-84 years. The fact that older females perceived their health as lower than did older males is of importance. Health policies and programmes need to promote healthy aging equitably.