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H. C. Hsu / Asian Journal of Health and Information Sciences, Vol. 1, No. 4, pp. 366-376, 2007
366
Gender Differences in Health-related Quality of Life
among the Elderly in Taiwan
H
UI-
C
HUAN
H
SU
*
Department of Healthcare Administration, Asia University, Taiwan
ABSTRACT
Purpose: This study examines the gender disparity in the elderly’s health-related quality of life in
Taiwan. Method: Data came from the National Health Interview Survey, a series of
nation-representative face-to-face interviews held in Taiwan in 2001. The samples were chosen from
those aged 65 or over, including populations drawn from the Taiwan area (with a number n=1845),
remote mountain areas (n=169), and offshore islands (n=179). Health-related quality of life (HQOL)
was measured by SF-36, including the dimensions of physical functioning, role limitation due to
physical problems, bodily pain, general health, vitality, social functioning, role limitation due to
emotional problems, and mental health. Two-stage linear regression models were used for analysis.
Results: Elderly women showed lower HQOL in almost every dimension in the Taiwan area and
offshore islands. After controlling for age, education, marital status, activities of daily living, and
numbers of chronic diseases, women elderly showed a lower score in HQOL than men, and the
difference was the most prominent in bodily pain which had a 23.6% lower score. The elderly in
offshore islands and mountain areas had a lower HQOL than that in the Taiwan area. Other effects were
greater than gender for the elderly in remote mountain areas. Discussion: Gender difference appeared
across different dimensions of health-related quality of life. More effort to improve equal gender
opportunities for health-related quality of life is necessary.
Key words: health inequality, elderly health, health-related quality of life, gender difference.
1. INTRODUCTION
Health inequality is the focus of recent health policy issues (Berkman &
Kawachi, 2000; Braveman, 2006; Curtis & Jones, 1998; Gakidou, Murray & Frenk,
2000; Gwatkin, 2002; Kawachi & Kennedy 2002; Marmot & Wilkinson 1999;
Pradhan, Sahn, & Younger, 2003). The differences of gender, socioeconomic status,
geographic area, and other groups are examined for their effects on health and
health care. The underlying advantages and disadvantages of social groups are
explored, and thus implications are provided for social and health policy. Usually,
the measure of health inequality has often been limited to mortality, with a lack of
consideration for health-related quality of life. Even where there have been studies
about health differences in health-related quality of life in Taiwan, the elderly’s
health inequality were less discussed. In this study I would like to examine the
gender disparity of health-related quality of life for the elderly in Taiwan.
The most widely cited definition of health inequality is that defined by
Whitehead (2000) in The Concepts and Principles of Equity and Heath. In this
WHO document Whitehead states that “Equity in health implies that ideally
everyone should have a fair opportunity to attain their full potential and, more
pragmatically, that no one should be disadvantaged from achieving this potential, if
it can be avoided,” and “Equity is therefore concerned with creating equal
*
E-mail: gingerhsu@asia.edu.tw
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367
opportunities for health and with bringing health differentials down to the lowest
level possible.” Bravemen (2006) commented that this definition is intuitive, clear
and accessible, but unjust, unfair, and avoidable: it is open to interpretation, and
does not provide guidance on measurement. Other researchers have discussed
thoroughly the concept and measures of health inequality (Braveman, 2004, 2006;
Gakidou et al., 2000; Mackenbach & Kunst, 1997; Murray, Gakidou, & Frenk,
1999; Regidor, 2004a, b; Wagstaff, Pact, & Doorslaer, 1991). They agreed that
equity in health should minimize the avoidable differences in health and its
determinants. They also tried to explicitly define the inequality in terms of
systematic and potential disadvantages across social groups, such as those defined
by gender, geography, socioeconomics, race/ethnicity/religion, and age, and
therefore provide policy implications.
Elderly women have many disadvantages in societies across the world.
Economic (income, food and nutrition, work environment, water and sanitation),
social (literacy, education, caregiving, widowhood), political (enfranchisement,
advocacy participation), and cultural (attitude to aging, attitudes to women’s
self-esteem) factors have made elderly women experience cumulative economic
barriers since youth, making them short of resources and contributing to a
deterioration in health (Bonita, 1998).
Gender difference in the health of the elderly has usually been found in health
services’ research (Chavers, Gilbert, & Shelton, 2002; Degl'Innocenti et al., 2002;
Friedman, 2003; Hsu, 2005; Koch et al., 2004; van Mil et al., 2000; Wijnhoven,
Kriegsman, Snoek, Hesselink, & de Haan, 2003), but many studies have only
focused on the specific diseases of patients, while a gender sensitive analysis was
lacking.
Although some evidence of health inequality has been found in Taiwan, most
studies have emphasized the differences in disease patterns and causes of death.
Health inequality research by more comprehensive and continuous measures of
health could be measured with relatively ease, but only a small amount of this kind
of research has been done. Actually, many scales of health-related quality of life
have been developed, validated, and widely applied, such as MOS (Tarlove et al.,
1989); MOS 36-item Short-Form Health Survey (SF-36) (McHorney, Ware &
Raczek, 1993); WHOQOL (The WHOQOL group, 1995); HRQoL (Bowling, 1997),
General Health Questionnaire (GHQ)(Goldberg & Hiller, 1979), etc. The
Taiwanese version of SF-36 (Lu, Ho, Lee, & Yen, 2003) has also been developed
and validated. However, research on the inequality in elderly health has been
uncommon. Only one study has used SF-36 to compare elderly health in urban,
rural, and remote islands (Tsai, Chi, Lee, & Chou, 2004). Significant differences
were found, but the samples were selected from three specific communities rather
than nation-representative samples.
In this study, “health equality” is used according to Whitehead’s definition.
Therefore, a health equality measure should represent not only the same level of
health, but also reflect the equal opportunities in health, such as the demands of
different roles and the various social functions. So health-related quality of life as
measured by Short-Form 36 was chosen as the measure of health. The health
H. C. Hsu / Asian Journal of Health and Information Sciences, Vol. 1, No. 4, pp. 366-376, 2007
368
inequality in gender in this study is explained from the viewpoint of there being
equal opportunities for health. The purpose of this study is to examine the gender
difference in health-related quality of life among the elderly in Taiwan, from
remote mountain areas and offshore islands, by nation-representative samples. This
paper will examine the gender inequality of health-related quality of life for the
elderly and therefore offer implications for health policy.
2. METHODS
2.1 Data and samples
The data was from “The 2001 National Health Interview Survey,” a Taiwan
population representative data. This survey included demographics, health status,
health behavior, medical utilization, and other health-related variables. The adult
participants were drawn by probability-proportional-to-size (PPS) sampling
respectively from the Taiwan area (sampling from seven life circles), remote
mountain areas (sampling from 30 districts in mountain area), and offshore islands
(sampling from offshore islands in four counties). Taiwan is a mountainous island
which is surrounded by small islands. People’s health in the mountain areas and the
island areas is, on average, lower than that of the general Taiwan area. The health
resources in remote mountain and island areas are also much fewer. Most of the
aboriginal groups live in mountain areas but some live on the offshore islands.
In this study, we used adult questionnaire data (aged 12 or over) and chose
only elderly samples aged 65 or over. The sample sizes were 2,064 for the Taiwan
area, 199 for mountain areas, and 196 for offshore islands. The sampling from the
three areas was independent, so these three sets of samples were not pooled
together for analysis in this study. Sample description is as shown in Table 1.
2.2 Measures
Health-related quality of life was measured by the Short-Form 36 (SF-36)
Taiwan version (Lu, et al., 2003), which included eight dimensions of physical
function, role limitations due to physical problems, bodily pain, general health,
vitality, social functioning, role limitation due to emotional problems, and mental
health. Some items were score reversed before calculation. After transformation, a
higher score indicates a better health-related quality of life. In this study none of the
scores were weighted.
Gender and geographic area were the main independent variables in the
models. Samples in the Taiwan area were further stratified to seven living circles to
analyze the heterogeneity within Taiwan. The other controlling factors to
health-related quality of life were demographics (age, educational level, ethnic
groups, and marital status) and health variables (disability and morbidity).
Disability was measured by activities of daily living (ADL), including eating,
dressing, transferring, walking indoors, taking a bath, and using the toilet. If the
participants had difficulty performing any one of the ADL items and the difficulty
lasted for more than three months, then he/she was judged to be ADL disabled.
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369
Morbidity was measured by the numbers of subjects currently having chronic
diseases, which included heart disease, respiratory disease, hypertension, diabetes,
high cholesterol, stroke, ulcer, nasosinusitis, liver disease, kidney disease, and
prostate or ovary/uterus disease.
Table 1. Sample description
Characteristics Taiwan area Offshore islands Mountain areas
Total persons (%) 2064(100.0) 196(100.0) 199(100.0)
Gender
Female 1008(48.8) 107(54.6) 112(58.9)
Male 1056(51.2) 89(45.4) 87(41.1)
Age
65-69 649(31.4) 60(30.6) 53(26.6)
70-74 644(31.2) 56(28.6) 77(38.7)
75-79 415(20.1) 34(17.3) 42(21.1)
80+ 356(17.2) 46(23.5) 27(13.5)
Education
Illiterate 692(33.6) 104(53.1) 83(41.7)
Elementary school 866(42.1) 75(38.3) 107(53.8)
Junior High school 190(9.2) 12(6.1) 2(1.0)
Senior High school 168(8.2) 2(1.0) 7(3.5)
College/University+ 145(7.0) 3(1.5) 0(0.0)
Ethnic Group
Mingnan 1456(70.5) 102(52.0) 16(8.0)
Hakka 163(7.9) 0(0.0) 17(8.5)
Mainlanders 401(19.4) 13(6.6) 10(5.0)
Aboriginal/others 44(2.1) 81(41.3) 156(78.4)
Marital Status
Having spouse 1350(65.4) 124(63.3) 102(51.2)
No spouse 714(34.6) 72(36.7) 97(48.8)
Note. 1. Samples who were literate but have not received formal education were categorized to elementary school.
2. Having spouse includes married and living together. No spouse includes being widowed, divorced, single, and
others.
2.3 Analysis
The gender difference stratified by geographic areas was analyzed by the
t-test. A two-stage linear regression was used to analyze the gender difference
within three geographic areas. Dependent variables were the scores of eight health
dimensions of SF-36. Gender was the main independent variable in the first stage,
while age, education, marital status, ADL disability, and chronic disease numbers
were second stage independent variables. Because there are heterogeneities in
Taiwan (remote mountains and offshore islands), the three samples were not pooled
but separated for analysis of the gender effect.
3. RESULTS
Table 2 examines the gender difference for each SF-36 dimension by
geographic stratification of the Taiwan area, mountain areas and offshore islands.
In the Taiwan area, women elderly were significantly lower than men elderly in all
HQOL dimensions. In the offshore islands, women had lower HQOL in general
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health, physical function, physical role limitation, emotional role limitation, bodily
pain, and vitality. In the mountain area, most of the HQOL dimensions were similar
in women and men, except the physical function; women was lower than men in
this aspect. However, the mean scores in these three areas were also different. The
scores in the Taiwan area were the highest in almost every dimension, except that
the offshore islands showed a higher score in physical role limitation and emotional
role limitation. Mountain areas showed the lowest score in every dimension of
SF-36.
Table 2. Gender difference of elderly’s health-related quality of life by SF-36 score,
stratified by geographic area
Dimensional HQOL by Area Total
mean (s.d.)
Women
mean (s.d.)
Men
mean (s.d.)
General Health
Taiwan area 18.27 *** 17.48 (4.97) 19.01 (4.87)
Offshore islands 17.92 * 17.26 (4.04) 18.64 (4.24)
Mountain areas 16.36 16.10 (4.01) 16.66 (4.65)
Physical Functioning
Taiwan area 23.95 *** 22.74 (5.45) 25.07 (5.11)
Offshore islands 22.89 *** 21.51 (5.13) 24.37 (5.14)
Mountain areas 22.40 * 21.59 (5.83) 23.34 (5.82)
Physical Role Limitation
Taiwan area 6.27 *** 5.94 (1.85) 6.57 (1.78)
Offshore islands 6.38 ** 5.93 (1.87) 6.86 (1.68)
Mountain areas 5.73 5.44 (1.72) 6.07 (1.95)
Emotional Role Limitation
Taiwan area 5.06 *** 4.89 (1.36) 5.22 (1.23)
Offshore islands 5.30 * 5.10 (1.33) 5.51 (1.02_
Mountain areas 4.69 4.72 (1.38) 4.66 (1.45)
Social Functioning
Taiwan area 8.31 *** 8.07 (1.95) 8.54 (1.79)
Offshore islands 8.22 7.98 (1.69) 8.48 (1.66)
Mountain areas 7.62 7.44 (1.88) 7.84 (1.72)
Bodily pain
Taiwan area 7.52 *** 6.95 (2.21) 8.04 (2.06)
Offshore islands 7.35 ** 6.87 (2.03) 7.88 (2.16)
Mountain areas 6.63 6.43 (1.87) 6.86 (2.09)
Vitality
Taiwan area 15.74 *** 14.97 (3.98) 16.44 (4.06)
Offshore islands 15.15 *** 14.16 (3.05) 16.20 (3.65)
Mountain areas 14.33 14.34 (3.43) 14.32 (3.98)
Mental Health
Taiwan area 22.80 *** 21.80 (4.58) 23.73 (4.36)
Offshore islands 22.70 22.10 (4.30) 23.35 (4.07)
Mountain areas 21.04 21.20 (3.70) 20.85 (4.17)
Note. Examined by t-test. *p<0.05, **p<0.01, ***p<0.001.
Gender difference by controlling other variables and stratified by geographic
area is shown in Table 3. Elderly women in the Taiwan area and the offshore
islands showed worse health in most of the health-related quality of life dimensions
after controlling other variables. However, gender difference was not found in the
mountain areas. In the eight dimensions of health-related quality of life, the greatest
Table 3. Gender difference of Health-related quality of life by geographic area stratification
Taiwan area General Health Physical
Functioning
Physical Role
Limitation
Emotional Role
Limitation
Social
Functioning
Bodily Pain Vitality Mental Health
Gender (Female) -0.154*** -0.198*** -0.170*** -0.118*** -0.125*** -0.236*** -0.171*** -0.197***
Age -0.014 -0.225*** -0.141*** -0.099*** -0.103** -0.079*** -0.060** 0.042
Education 0.007 0.015 0.011 0.021 -0.017 0.049* 0.006 0.005
Marital status -0.001 0.019 0.012 -0.014 0.042 0.004 -0.004 -0.021
ADL disability -0.285*** -0.468*** -0.243*** -0.207*** -0.372*** -0.306*** -0.296*** -0.263***
Chronic disease
no.
-0.302 -0.179*** -0.214*** -0.196*** -0.144*** -0.210 -0.207*** -0.171***
Adjusted R
2
0.219 0.413 0.180 0.125 0.213 0.234 0.189 0.151
Offshore Islands General Health Physical
Functioning
Physical Role
Limitation
Emotional Role
Limitation
Social
Functioning
Bodily Pain Vitality Mental Health
Gender (Female) -0.143 -0.229** -0.320*** -0.173* -0.155 -0.216* -0.190* -0.080
Age 0.001 -0.168* -0.139 0.068 -0.081 -0.026 -0.009 0.018
Education 0.086 0.092 -0.086 0.042 -0.005 0.088 0.163 0.117
Marital status 0.048 0.075 -0.024 -0.011 0.026 -0.018 0.124 0.051
ADL disability -0.042 -0.276*** -0.170* -0.074 -0.184* -0.148* -0.004 -0.028
Chronic disease
no.
-0.347 -0.231** -0.299*** -0.282*** -0.198* -0.338*** -0.241** -0.125
Adjusted R
2
0.128 0.260 0.182 0.099 0.082 0.183 0.139 0.014
Mountain Area General Health Physical
Functioning
Physical Role
Limitation
Emotional Role
Limitation
Social
Functioning
Bodily Pain Vitality Mental Health
Gender (Female) 0.015 -0.053 -0.103 0.095 -0.045 -0.015 0.103 0.106
Age -0.150* -0.139* -0.089 -0.086 -0.125 -0.010 -0.014 -0.032
Education 0.118 0.111 -0.009 0.203* 0.010 0.063 0.152* 0.136
Marital status 0.037 0.008 0.089 -0.009 0.016 0.054 0.039 -0.024
ADL disability -0.251** -0.542*** -0.303*** 0.264** -0.431*** -0.405*** -0.341*** -0.264**
Chronic disease
no.
-0.337*** -0.246*** -0.139 -0.130 -0.163* -0.250*** -0.268*** -0.211**
Adjusted R
2
0.204 0.419 0.135 0.122 0.028 0.223 0.192 0.105
Note 1: A two-stage linear regression is used for analysis; gender is put in the first stage. The standardized coefficients are listed in the table. A constant is omitted. The score is not weighted; a
higher score means better health. The coefficients are standardized.
Note 2: Education is counted by educational year. Marital status (1=married or living together, 0=single, divorce, widowed, others). ADL disability means if there is any difficulty of any one item
from eating, dressing, transferring, walking indoors, bathing, and using the toilet, and the difficulty has lasted for more than three months (1=difficulties in any one item, 0=none). Chronic
diseases include hearing disease, respiratory disease, hypertension, diabetes, high cholesterol, stroke, ulcer, nasosinusitis, liver disease, kidney disease, and prostate or ovary/uterus disease.
Note 3: Reference group of independent variables: Gender (male), age (continuous), educational year (continuous), marital status (no spouse), ADL disability (none), and number of chronic
diseases (continuous).
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disparity between men and women for the Taiwan area was bodily pain (r =
−0.236). Next were mental health (r = −0.197) and physical functioning (r =
−0.170). As for the offshore islands, the greatest disparities between the two
genders were physical role limitation (r = −0.320), physical functioning (r =
−0.229), and bodily pain (r = −0.216).
Being older appeared to be worse in six health dimensions for the Taiwan
elderly, except for general health and mental health. The elderly of the offshore
islands’ were only worse in physical functioning, while the elderly from the
mountains were only worse in general health and physical functioning. Having any
ADL disability and more chronic diseases showed a worse health-related quality of
life across three areas. Educational level and marital status were not significant at
all. The variance across the models were quite different (R square ranged from 0.01
to 0.42), with the physical functioning model giving the best explanation and the
mental health model giving the least probable explanation.
4. DISCUSSION
In this study, SF-36 was used as the measure of health-related quality of life,
and found gender differences in the elderly in Taiwan. Elderly women showed a
lower health-related quality of life, while the elderly in offshore islands and
mountain areas had a lower HQOL than those in the Taiwan area.
Consistent with past studies (Friedman, 2003; Koch et al., 2004; Wjinhoven
et al., 2003), we have shown that older women have a lower health-related quality
of life in general, or in some dimensions. In another Taiwan study, elderly women
also had less successful aging than elderly men and this may possibly be related to
cumulative disadvantages (Hsu, 2005). In this study the gender difference in HQOL
was significant, but with a varying pattern in geographic areas. In the Taiwan area,
women had lower HQOL in every dimension, especially in bodily pain, physical
functioning, and mental health, which is consistent with other studies (Friedman,
2003; Koch et al., 2004; Wjinhoven et al., 2003). Women’s lower HQOL might be
related to poorer recovery from illness in physical function (Friedman, 2003), or a
high level of depression and anxiety related to the disease severity (Wjinhoven et
al., 2003). But in the offshore islands elderly women felt in poorer health in their
roles, physical function, pain, or vitality. These dimensions all reflected some kinds
of demands from their roles or functions, which may be related to gender. It is
possible that elderly women need to carry more responsibilities, perform more
physical activity or have taxing family roles. The opportunities for health-related
quality of life were not equally gender-distributed.
Gender difference was not found in remote mountain areas. However, the
health in mountain areas was the lowest in every dimension compared to the
Taiwan area and offshore islands. It implies that the geographic inequality is
greater than gender differences for mountain areas, especially for the aboriginal
groups. In the past, the aboriginal group had less opportunity for education, a lower
socio-economic status, and less health care resource than in the Taiwan area. They
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also have higher social isolation and lack of cultural stimulation in these rural areas.
Some behavior related to poor health was also more prevalent in the mountain areas
(Hurng et al., 2000; Lu, Tseng & Tsai, 2003). Public health effort is still needed
and social infrastructure for the remote mountain areas is necessary to improve the
situation.
Geographic health inequality is also an important field in health inequality
issues. Curtis & Jones (1998) explain the geographic differences by compositional
(individual) and contextual effects. The contextual effects are interpreted by the
spatial patterning and diffusion of physical and biological risk factors, the role of
space and place in social relations important for health; and a sense of place helps
to understand the significance of health. Geographic effect is often related to
different exposures to health risks, inequity in access to health care, or income
inequality (Krieger, 1999; Marmot & Wilkinson, 1999). The geographic difference
in the elderly’s health-related quality of life may be related to the unfair
opportunity for the same level of quality of health. The life for farmers is usually
labor-intensive, and reduced access to health care may influence their health. These
elderly are also more likely to have a low income, or worry about economic
security after retirement (Ministry of Interior, 2002).
This study has some limitations. First, the samples of the offshore islands and
remote mountain areas were limited. The samples were drawn from the 2001
National Health Interview Survey. Although the sampling was over-weighted for
selecting more from the offshore islands and mountain area samples, the available
samples were still limited. Secondly, multi-level analysis was not applied in this
study, and personal characteristics were only used for control in the models. The
main reasons include that the offshore islands and mountain areas samples were
limited and the sampling method in the survey was without city/county
representation. Thus this study only compared the differences in the Taiwan area,
offshore islands, and mountain areas by stratification. In addition, this study
analyzed the absolute difference rather than a single index of distribution, and
therefore the dissimilarity or distribution of health inequality was not represented
(Regidor, 2004 a, b). Third, for many cases the income variable was missing or
unavailable for analysis. Additionally, most of the elderly do not have work.
Educational level was the only socio-economic status variable to be controlled in
the analysis.
Gender difference of the elderly’s health-related quality of life exists in
geographic area in Taiwan. Although National Health Insurance is implemented to
remove the financial access risk, and public health efforts were made for health
care distribution equity, there seems to be health inequality for the elderly. The
unfair opportunity that impedes the health-related quality of life for women needs
to be examined, and gender sensitivity analysis should be applied to health policy
to create equal opportunities for health and quality of life for both genders. In
addition, further studies are suggested to examine the geographic difference in
health inequality within Taiwan, to examine the underlying factors of geographic
and individual levels by multi-level analysis, and to explore the relations between
health and geography with intensive qualitative research.
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ACKNOWLEDGEMENTS
This research was supported by grants from the National Science Council,
Taiwan, R.O.C., under the project “Elderly women’s health problems and
improving strategies” (NSC 93-2621-Z-468-001). This study is based on data from
the National Health Interview Survey Original Database provided by the Bureau of
Health Promotion, Department of Health and National Health Research Institutes.
The interpretation and conclusions contained herein do not represent those of
Bureau of Health Promotion, Department of Health or National Health Research
Institutes. The author also thanks the anonymous reviewers’ for their comments,
and Mr. Gerald Irby’s help in English editing.
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Hui-Chuan Hsu received her Ph.D. in health policy
and management from National Taiwan University, Taipei,
Taiwan in 2001. She served in Department of Planning,
National Taiwan University Hospital in 1998-2000, and
National Taipei College of Nursing as a part-time lecturer
in 2000-2001. She is currently an Associate Professor in
the Department of Department of Healthcare
Administration at Asia University, Taiwan. Her current
research interests include successful aging, social
gerontology, and long-term care policy.
