Effect of age, education and health status on community dwelling older men’s health concerns

Abstract

Introduction: A significant gap in evidence characterizes the process of establishing patient-centered health priorities for older men. Methods: A cross-sectional postal survey of 2325 Canadian community dwelling men aged 55–97 years old was conducted in 2008 to gauge older men’s level of concern for 24 different health items, to determine the impact of age, education and health status on these perceptions, and to ascertain whether men perceive that their health concerns are being attended to. Results: Health issues of greatest concern to men were mobility impairment (64% of respondents), memory loss (64%), and medication side effects (63%). Respondents with lower educational attainment expressed greater concern about their health and were almost 2-fold times more likely to report being concerned about stroke, heart disease and prostate disorders in analyses that controlled for age and health status. Physical and mental health were independently associated with various concerns about health, but old age was not a reliable predictor, with only younger men (<75 years old) differentially preoccupied by conditions such as erectile dysfunction. Health items of greatest concern to men tended to be those with the lowest screening or counseling rates: these included incontinence, osteoporosis, mobility impairment, falls, anxiety issues, memory loss and depression. Conclusion: An improved consumer-guided agenda for addressing older men’s health in the coming decade is urgently required.

Keywords::

• Aging
• health concerns
• older men
• service delivery
• survey

Introduction

A key aspect in the development of policies and strategies to address male aging and health involves men’s input about issues of greatest importance to them. Unfortunately, little is known about older men’s level of concern for specific age-related health threats, men’s priorities as they age, and whether or not older men perceive their health concerns as being attended to. Several factors may influence men’s health concerns: education, age, experiences of friends and family, physical and mental health status. Without insight into items of importance to older men and the factors that drive these concerns, drafting an agenda to meet older men’s needs will remain a challenging prospect.

An additional rationale for understanding the way men prioritize health issues relates to the effect it may have on their health trajectory, which differs significantly from women’s [1,2]. In developed countries, men’s life expectancy lags 5 years behind women’s, with men experiencing higher death rates for all 15 leading causes of death [3–5]. Men experience one-and-a-half-times greater age-adjusted rates of death from heart disease and cancer; a 2-fold higher mortality from Parkinson’s disease, liver disease and accidents and are four times more likely to commit suicide [4,5]. Data on older women’s health concerns have recently become available [6,7], but a comparison with same-aged men’s health priorities remains elusive due to a lack of information on men. The current study was undertaken to generate knowledge on older men’s health concerns and to determine whether age, education, or physical and mental health status influence these perceptions.

Methods

Participants and measures

A cross-sectional postal survey of community dwelling men aged 55 years and older from across Canada was conducted in May 2008. The survey questionnaire queried the importance of 24 health items of potential concern to men. Health concern items were generated from seven focus groups with 48 community dwelling men aged 59–89 years (mean 72 ± 6.5) during the previous year. First, men were asked in open-ended format to discuss any health items of concern to them [8]. Second, the participants were presented with a list of health concerns generated from previous work with older women and asked to comment on their relevance [7]. Omissions and deletions were negotiated based on feedback from the original open-ended questions. After several iterations, 24 health items of relevance to older men were retained. A pilot questionnaire that listed these 24 items was then distributed to 250 older male patients recruited from the waiting room of an ambulatory clinic center off the island of Montreal to test for validity of the items and to ensure that all items were endorsed. No modifications were required following this pilot testing.

The final items included in the questionnaire were eight disease-related conditions (heart disease, stroke, colon cancer, prostate disease, diabetes, osteoporosis, pneumonia, Alzheimer’s disease), eight issues related to function (falls, memory loss, vision loss, hearing loss, loss of muscle strength, mobility impairment, urine leakage, pain,) and eight psychosocial concerns (exercise, nutrition, anxiety, depression, medication side effects, end of life care, erectile dysfunction, sleep difficulties). Respondents were asked to gauge their level of concern (greatly, somewhat, a little, or not at all concerned) for each item. Perceptions of the care men received to address these health items were obtained by asking respondents to indicate whether or not they recalled receiving screening procedures or counseling from any of their health care providers to address each of the 24 items. Whenever possible, the frequency and type of screening was queried according to national recommendations. For heart disease and stroke, men were queried on blood pressure measurements and cholesterol screening. For Alzheimer’s disease, men were asked about memory testing, and for colon cancer men were queried on yearly stool screening for occult blood, or colonoscopy or sigmoidoscopy screening every 5 years. For prostate disease, men were asked whether their doctor checked their prostate yearly. Screening for osteoporosis was considered positive if men indicated that they had ever undergone bone density testing or bone x-rays to check for brittle bones. For diabetes and pneumonia, men were asked whether they received blood tests to check for high blood sugar at least every 3 years, and whether they received a flu vaccine yearly. For each of the other health conditions, men were simply asked to indicate whether any of their health providers had ever addressed each of the items with them (yes, no).

Standard socio-demographic information on age, education, marital status and self-reported health conditions and prescription medications was collected. Participants were asked to write their age in years at the time of completion of the survey. Educational level was categorized as low− having completed elementary school or secondary school (approximately 11 years of education), versus high− going on to achieve a college or university degree. Self-rated physical and mental health was measured by the Physical Component Subscale (PCS12) and Mental Component Subscale (MCS12), respectively, of the Medical Outcomes Study: Short-Form-12 survey. This measure has been validated in older adults and allows for comparison of the study sample with normative health status data for older Canadian men [9,10].

The sampling frame for the survey consisted of all households across Canada whose addresses were registered with Canada Post. Men who responded to two household level Canada Post surveys during the year 2006 made up the study list sample. A computer-generated random sample of 5000 names and addresses of men aged 55 years and older was obtained from the Canada Post respondent list to constitute the study sample. Men aged 65 years and older were over-sampled to ensure adequate representation of older age groups. The study sample was considered a convenience sample rather than a representative sample of older Canadian males, as the list from which the sample was obtained comprised only 15–18% of all Canadian households (although each and every household in Canada receives a semi-annual Canada Post survey, only 15–18% of households respond). In order to ascertain how representative the respondents were compared to other older male Canadians, comparisons were made with national data on basic socio-demographic and health characteristics.

The survey’s self-administered questionnaire was mailed only once to participants with pre-stamped return envelopes. Men who had originally responded to the Canada Post survey in French were mailed French questionnaires. Questionnaires that were returned within 6 months of the mail-out date were included in the analyses.

Analysis

Descriptive statistics were used to estimate proportions of men from the survey with specific health concerns, as well as their perception of the care received to address these concerns. Health items were dichotomized into “of great concern or importance” or “not of great concern or importance” (somewhat, a little bit and not at all) for all analyses. Because of the large sample size, 95% confidence intervals were within 2% points for each of the estimates and are not reported in the tables. To determine whether age (categorized as <75 vs. 75+), education level (cut-off at 11 years of education to designate low or high educational attainment), or physical or mental health status (lowest quartile vs. top three-quarters of PCS12 or MCS12 scores, respectively) influenced the endorsement of specific health priorities, the latter variables were regressed in a logistic model against the probability of selecting each health priority. As health status was significantly related to educational attainment in this sample, multivariate logistic analyses were performed for each health item to adjust for age, education and physical and mental health status. Results are reported for the multivariate analyses and are expressed as odds ratios with 95% confidence intervals.

Each health concern item had less than 5% missing data. Imputation of missing data was conducted using an explicit model-based approach with selected, highly correlated variables [10]. Item means and standard deviations did not vary significantly following data imputation. All analyses were conducted using the SAS software package (version 9.1, SAS Institute, Cary NC).

Ethical approval

The study was approved by the Ethics Board of the Institut universitaire de gériatrie de Montréal.

Results

Sample description

Two-thousand three hundred and twenty-five men responded to the cross-national survey, representing a 47% response rate. Table I shows the characteristics of the respondents and compares them to Canadian national statistics for same-aged men. The average age of the respondents was 72.9 ± 7.0 (range 55–97). Participants in the survey were strikingly representative of the national average, except for being better educated and more likely to be retired from the workforce.

Table I.  Respondent characteristics.

	n = 2325	Normative data
Age (mean ± SD)	72.9 ± 7.0	Men aged 55 years and older made up 25% of Canada’s male population in 2010; [13]
range	55–97
Marital status
Married	71.3%	71.0% [14]
Widowed	12.0%	4.6% [14]
Divorced	10.0%	10.0% [14]
Never married	6.7%	7.2% [14]
Living alone	22.5%	26.9% [15]
Caucasian	90.3%	87.7% [16]
University or college education	35.2%	21.1% [17]
Employment status
Working fulltime	6.1%	25.5% [14]
Part time or once in awhile	11.7%	22.1% [14]
Fully retired	82.2.%	52.4% [14]
Perceived health status
Excellent or very good	47.3%	42.1% [18]
Good	37.3%	33.9% [18]
Fair or poor	15.4%	24.0% [18]
Health conditions
High blood pressure	47.6%	44.9% [18]
Diabetes	21.3%	22.1% [18]
Arthritis	41.8%	32.3% [18]
Physical health (PCS12)* (mean ± SD)	44.9 ± 10.5	46.7 [10]
Mental health (MCS12)* (mean ± SD)	54.1 ± 8.2	54.8 [10]

*Higher scores denote better health. Possible range 0–100.

Men’s health concerns and perceptions of care

Men’s health concerns are ranked in descending order in Table II according to functional, psychosocial or disease-related categories. The health issues of greatest concern to men were mobility impairment (64% of respondents), memory loss (64%), and medication side effects (63%). Men were generally more concerned about conditions that could affect their ability to function independently, such as vision and hearing loss, than with the thought of contracting pneumonia. Less than one-third of respondents reported being greatly concerned about heart disease, diabetes, nutrition or physical activity. With the exception of being informed about medication side effects, health items of greatest concern to men were those for which they had not been screened or counseled. For instance, less than 20% of respondents reported that their health providers addressed incontinence, osteoporosis, mobility impairment, falls or anxiety issues, and only 9% reported receiving screening for memory loss or depression. On the other hand, over 94% of men recalled having their blood pressure and cholesterol checked for prevention of heart disease and stroke, and 85% recalling having been screened or treated for diabetes.

Table II.  Men’s health concerns and perceptions of care.

	Proportion of men who are greatly concerned about this health issue/ judge it to be very important	Proportion of men reporting that providers screen, treat or address this health issue
Function-related concerns
Mobility impairment	64.4%	13.2%
Memory loss	63.6%	8.8%
Vision loss	60.6%	40.9%
Hearing loss	52.0%	29.3%
Falls	50.8%	11.9%
Loss of muscle strength	42.5%	19.0%
Urine leakage	42.2%	17.8%
Pain	40.6%	32.0%
Psychosocial issues
Medication side effects	62.7%	84.5%
Depression	44.8%	9.5%
Sleep difficulties	37.7%	20.7%
Erectile dysfunction	35.7%	25.4%
Nutrition	32.7%	41.8%
Anxiety	27.1%	17.0%
End of life care	27.0%	11.8%
Exercise	20.5%	41.9%
Disease-related conditions
Osteoporosis	44.6%	13.5%
Alzheimer’s disease	35.8%	15.8%
Stroke	35.5%	96.0%
Prostate disease	34.4%	81.4%
Colon cancer	33.5%	55.5%
Heart disease	29.7%	94.1%
Diabetes	23.7%	87.5%
Pneumonia	19.4%	81.7%

Effects of age, education, physical and mental health status

Men with lower education were found to have poorer health in this sample. Twenty-seven percent and 26% of men with lower educational attainment ranked in the lowest physical and mental health quartiles, respectively, in contrast to only 21% of those who completed college or university (p < 0.01). In order to control for confounding by health status, multivariate logistic regression analyses were performed to adjust for age, education, physical and mental health. Results from these regressions revealed that respondents who did not obtain college or university degrees consistently expressed greater concern for all health items compared to men with higher education, except for exercise, nutrition, medication side effects, pain, falls and vision loss (Table III). For example, men with lower education were almost 2-fold times more likely to report being concerned about stroke, heart disease and diabetes than their more educated counterparts. Poor health was also independently associated with various health concerns, even when adjusted for educational attainment. Men with compromised physical health were more likely to attribute importance to mobility impairment, falls, loss of muscle strength, medication side effects, stroke, heart disease, diabetes, pneumonia, prostate disease, pain, end of life care and exercise. Respondents rating their mental health in the lowest quartile of MCS12 scores emphasized concern about depression, anxiety, sleep difficulties, end of life care, pneumonia, Alzheimer’s disease, prostate disease, stroke, diabetes and colon cancer. Younger age was significantly associated with concerns about erectile dysfunction, depression, pain and memory loss, even when health status was adjusted for. Older age had no association with any of the other health items when education, physical and mental health status were accounted for in the analyses.

Table III.  Effect of education, physical and mental health status, and age on health concerns.

	Adjusted odds ratios (95% confidence intervals)*
	Lower level of education	Poor physical health	Poor mental health	Older age (75+)
Function-related concerns
Mobility impairment	1.5 (1.2–1.8)	1.7 (1.3–2.4)	1.2 (0.9–1.6)	0.8 (0.6–1.0)
Memory loss	1.3 (1.0–1.7)	0.9 (0.7–1.3)	1.1 (0.8–1.4)	0.7 (0.5–0.8)
Vision loss	1.2 (1.0–1.6)	1.1 (0.8–1.4)	1.3 (1.0–1.8)	0.8 (0.6–1.0)
Hearing loss	1.5 (1.2–1.9)	0.9 (0.7–1.1)	1.1 (0.8–1.5)	1.0 (0.7–1.2)
Falls	1.2 (1.0–1.5)	1.5 (1.2–2.0)	0.9 (0.7–1.2)	1.1 (0.9–1.3)
Loss of muscle strength	1.5 (1.2–1.9)	1.7 (1.3–2.4)	1.2 (0.9–1.7)	0.8 (0.7–1.1)
Urine leakage	1.5 (1.2–1.8)	1.1 (0.9–1.4)	1.0 (0.8–1.3)	1.0 (0.8–1.2)
Pain	1.2 (1.0–1.5)	2.1 (1.6–2.7)	1.3 (1.0–1.7)	0.7 (0.6–0.9)
Psychosocial issues
Medication side effects	1.1 (0.9–1.5)	1.6 (1.1–2.2)	1.2 (0.9–1.7)	1.1 (0.8–1.4)
Depression	1.4 (1.2–1.7)	0.9 (0.7–1.1)	1.9 (1.5–2.4)	0.8 (0.6–0.9)
Sleep difficulties	1.5 (1.2–1.8)	1.2 (0.9–1.5)	2.1 (1.6–2.7)	0.8 (0.7–1.0)
Erectile dysfunction	1.6 (1.3–1.9)	0.8 (0.7–1.0)	1.1 (0.9–1.4)	0.6 (0.5–0.7)
Nutrition	1.0 (0.8–1.2)	1.2 (0.9–1.5)	1.2 (0.9–1.5)	1.1 (0.9–1.3)
Anxiety	1.6 (1.3–2.0)	1.2 (1.0–1.6)	1.8 (1.4–2.3)	0.8 (0.7–1.0)
End of life care	1.3 (1.1–1.8)	1.4 (1.1–1.7)	1.5 (1.2–1.9)	1.1 (0.9–1.4)
Exercise	1.0 (0.8–1.2)	1.3 (1.1–1.7)	1.1 (0.9–1.4)	0.8 (0.7–1.0)
Disease-related conditions
Osteoporosis	1.4 (1.2–1.7)	1.2 (0.9–1.5)	0.9 (0.7–1.1)	0.9 (0.8–1.1)
Alzheimer’s disease	1.7 (1.4–2.0)	0.9 (0.8–1.2)	1.5 (1.2–1.9)	0.9 (0.7–1.1)
Stroke	1.9 (1.6–2.3)	1.3 (1.1–1.7)	1.4 (1.1–1.7)	0.9 (0.8–1.1)
Prostate disease	1.9 (1.6–2.3)	1.5 (1.1–1.8)	1.5 (1.2–2.0)	0.9 (0.7–1.1)
Colon cancer	1.8 (1.5–2.2)	1.2 (0.9–1.4)	1.4 (1.1–1.7)	1.0 (0.8–1.2)
Heart disease	1.9 (1.6–2.3)	1.4 (1.1–1.8)	1.3 (1.0–1.6)	1.0 (0.8–1.2)
Diabetes	1.8 (1.5–2.2)	1.7 (1.3–2.1)	1.3 (1.1–1.6)	0.8 (0.7–1.0)
Pneumonia	1.8 (1.5–2.1)	1.6 (1.3–2.0)	1.3 (1.1–1.6)	0.9 (0.8–1.1)

*All results are adjusted for education, PCS12, MCS12 and age in multivariate logistic regression analyses.

Odds ratios whose 95% confidence intervals do not span 1.0 are significant and are highlighted in bold.

Discussion

Our findings reveal that more than half of all older men may be preoccupied by health threats encompassing mobility impairment, memory loss, medication side effects and other conditions affecting their autonomy. Concerns about mental health (depression) and functional decline (loss of muscle strength) exceeded concern about specific disease states (prostate disease, colon cancer). Men with lower educational status were significantly more likely to attribute importance to various functional, disease and psychosocial-related health items than men with higher educational attainment, even when health status was controlled for in the analyses. Poor physical and mental health predicted a number of health concerns, but old age was surprisingly impartial, with younger men being more concerned about conditions such as erectile dysfunction. In general, health items that appeared least attended to by health professionals elicited the greatest concern among respondents. Examples include many of the geriatric syndromes such as cognitive impairment, falls and incontinence.

As this Canadian survey is the first to query older men’s concerns about their health, it is difficult to compare the results with men’s anticipated responses in other developed or developing countries. Validation of the men’s perceptions about the care they receive to address their health concerns is more feasible, as objective measurement from other research indicates that men’s recall of their care may be exact. Wenger et al. reviewed medical records and performed quality-of-care interviews with a random sample of 372 vulnerable elders in the United States, of whom 34% were men [11]. Though not disaggregated by sex, the results indicate that care delivered for appropriate medication, vision and hypertension management was high (80, 79 and 77%, respectively), but that only a third of the sample passed quality indicators for conditions such as osteoporosis, urinary incontinence, falls, dementia and depression. Use of claims data from a larger population of 100,528 patients confirmed these findings, with osteoporosis, dementia and depression found to be neglected in over two-thirds of cases [12]. These trends are mirrored by the responses obtained in the current survey, suggesting that men’s perceptions of the care they receive may be fairly accurate, and reflect patterns of actual care for older men.

Deficiencies in care patterns may lead patients to worry that certain aspects of their health are being neglected, putting them at higher risk for adverse outcomes. Men who are more informed about their health may be better equipped to address these concerns and allay uncertainty surrounding their health. One explanation for the finding that men with lower education were more inclined to express concern about the majority of health items listed in our health survey relates to the possibility that more educated men may have better access to health information, for instance through use of the internet. If this hypothesis is correct, then a need exists for better access to health information for older men with lower educational status who may not know how to access information related to their health.

The results of this survey unmask an important juxtaposition between societal and individual perspectives regarding preventive health screening and counseling. Conditions which might be considered more important from a public health or policy standpoint, such as heart disease and diabetes, elicited the least concern among the respondents, whereas issues of greatest importance to older men such as preservation of mobility, strength, memory and continence received the lowest screening rates. The paradox that older men list as health priorities functional and quality of life items that are least attended to by health professionals raises an important question regarding the delivery of medical care− who, in the end, is the consumer? Do men’s concerns matter to allocation of resources, or should the latter be driven by morbidity and mortality data? Heart disease, stroke and diabetes did not figure prominently in the list of items of greatest concern to the majority of older men, yet the investment in health care resources and pharmaceuticals to prevent and treat these conditions is astronomical. If governments hope to gain the support of older male citizens in developing new health care reimbursement policies, should they not seek men’s input on the concerns that matter most to them?

Several limitations to our survey warrant mention. The health items included in the survey were validated by a group of community dwelling older men and appear to hold face validity for the full range of ailments, functional issues and psychosocial concerns experienced by older adults. Nonetheless, the survey respondents represent a relatively healthy, retired group of older men and likely do not represent the marked heterogeneity of all older men of different backgrounds. Concerns and perceptions of care could reasonably be different for non-responders or sicker men, men who are not interested or capable of answering surveys, or those who are bed-bound or institutionalized. Additionally, only a single mail-out of the survey was sent. The response rate may have been improved had follow-up reminders been provided.

In conclusion, an improved agenda for addressing older men’s health in the coming decade might include alternate ways of disseminating health information to illiterate or more poorly educated older men, de-stigmatizing mental health conditions in the trajectory of care, actively querying men about their health concerns during routine clinical visits, and better addressing geriatric syndromes. The health items elicited in this study could be used as a checklist for practitioners. Screening for depression is paramount, especially during mid-life and retirement transitions. Addressing risk factors for and aggressively treating common geriatric syndromes, such as mobility and cognitive impairment, falls, loss of muscle strength and urinary incontinence should become routine. Further research needs to evaluate whether addressing men’s health concerns results in measurable improvements in health outcomes and longevity.

Declaration of Interest: This work was supported by the Canadian Institutes of Health Research, grant number 200706BMH-176110-BMH-CFCL-108262.