This analysis assessed the factors accounting for differences between older women and men in reported disability in Ismailia, Egypt. The analysis was based on rich data from an extensive population-based survey of adults 50 years or older that included a full set of in-home tests of physical functioning. Following other research (Guralnik, Branch, Cummings, & Curb, 1989
; Merrill et al., 1997
; Rahman & Liu, 2000
), the analysis showed that objective functional status strongly predicted self-reports of disability. In addition, other attributes including doctor-diagnosed morbidities, access to and use of health care, socioeconomic status, and social relationship were significantly associated with self-reports of disability. Large differences between women and men in all of these attributes raised questions about which variables accounted for gaps in self-reported disability.
Our results showed that, compared with older men, older women more often reported higher levels of difficulty with ADLs, ROM, and GM. Differences between women and men were especially pronounced for self-reported GM disability. Furthermore, women compared with men performed worse on objective tests of physical functioning and more often reported disabling morbidities and lower socioeconomic status.
Adjusting for age and objective measures of physical performance eliminated differences between women and men in their reported difficulty with ADLs; yet, differences in reported difficulties with ROM and GM remained after adjusting for these objective measures. In the full model that also controlled for reported morbidities and access to/use of health care as well as socioeconomic status and social relationships, the latter variables accounted for the largest proportions of residual gaps in self-reported disability. However, in full models that adjusted for age, objective functioning, and other reported health, economic, and social conditions, women maintained significantly higher proportional odds of reporting difficulty with ROM and GM.
These residual gaps in reported disability may result from unmeasured gaps in men’s and women’s (a) functional performance, (b) reported morbidity and access to/use of health care, and/or (c) socioeconomic status and social relationships. Most notable are potential unmeasured gaps in BMI. Among adults in the Middle East including Egypt, women are obese more often than men (Galal, 2002
; Yount, 2012
), and body weight strongly predicts lower-extremity disabilities (Himes, 2000
; Simonsick et al., 2001
). Thus, unmeasured differences in BMI in this sample may account for residual gaps in reported disability. Many studies in western societies have disclosed the strong relationship between BMI and reported physical limitations. Stenholm and colleagues (2007)
argued that obesity can lead to the avoidance of physical activity, which in turn, can contribute to a heightened perception of physical limitation. Larsson and Mattsson (2001a
, 2001b) revealed that in comparison with normal weight women, obese women were more likely to perceive more difficulties in performing physical activities and more likely to feel more physical demands and pain with strenuous work even after controlling for their objective measures of physical activities. Other researchers have pointed to gender differences in the psychosocial affect of obesity on personal well being. Compared with men, obese women were more likely to experience anxiety, depressive disordered, and lower self-esteem (Kearney-Cooke, 1999; Osei-Assibey, Kyrou, Saravanan, & Matyka, 2010
; Tuthill et al., 2006).
Also notable were unmeasured social roles that may affect men’s and women’s perceptions of disability. On becoming a mother-in-law or grandmother, for example, older Egyptian women achieve more family power, and may delegate daily chores especially to junior women and grandchildren, limiting their mobility and engagement in household activities (Yount, 2005
). In contrast, men often remain family providers into their later years and continue to engage in the labor market (Khadr, 2004
). These differences in social roles may confound reports of “disability.” Finally, residual gaps in reported disability may result from gendered socialization, which teach women and men to perceive disability differently. In such cases, a residual gap in reported disability would remain after controlling for gaps in other characteristics. That a residual gender gap does not remain for reported difficulty with ADLs suggests that gender gaps in reporting may be less relevant for extreme levels and forms of disability.
To some extent, the results from Ismailia depart from those in other highly gender-stratified settings (Rahman & Liu, 2000
). In Bangladesh, for example, gaps in any reported difficulty
with ADLs persisted after adjusting for age and objective performance (Rahman & Liu, 2000
). These differences across settings may be attributed to the greater tendency of Bangladeshi women to over-report ADL disability, variation across studies in the measurement of ADL limitation, or the inclusion of more controls for objective function in the Egyptian sample. The results in Ismailia also departed from those in the United States (Merrill et al., 1997
), where differences in GM limitation disappeared after adjusting for age and objective performance. These differences across settings may result from Egyptian women’s greater tendency to over-report GM limitations or to higher levels of (unmeasured) obesity in Egyptian women. Together, differences in findings across more (Bangladesh and Egypt) and less (United States) gender-stratified settings suggest that women’s and men’s reports of physical limitations may be associated with the degree of gender equality in society.
Notably, the cross-sectional nature of these data precluded the inclusion of other variables that have been associated elsewhere with reported disability. Such factors include the early life experiences that predict later-life health and physical functioning, especially in women (Watt et. al., 2009; Kasper et. al. 2008; Hilldson et. al. 2006). Childhood poverty, psychological status, health behaviors, and the quality of social relationships may affect or be affected by health in old age (e.g., Armenian Pratt, Gallo, & Eaton, 1998
; Bruce, Seeman, Merrill, & Blazer, 1994
; Hilldson et. al. 2006; Kasper et. al. 2008; Ormel, Rijsdijk, Sullivan, Sonderen, & Kempen, 2002
; Watt et al., 2009). The distributions of some of these attributes differ for older women and men and the inclusion of these variables in full multivariate models accounted for some but not all of the residual gaps in reported disability (results available on request). To assess the causal relationships among these variables would require repeated measures over time and data on instrumental variables to account for their potential endogeneity.
Together, the findings from this analysis corroborate those from other research in the region (Yount & Agree, 2005
) and suggest that collecting self-reports of difficulty with basic ADLs may be an appropriate and cost-effective way to compare actual levels of ADL disability across genders and contexts. However, although self-reports of difficulty with ROM and GM are meant to capture disability in a standard social environment, group differences in perceptions and social roles may systematically affect the responses to these questions. Thus, in a highly gender-stratified society like Egypt, these self-reported measures may offer insights about differences between women and men in their perceived needs for care; yet, these measures may provide a biased picture of disparities in objective functional status. In this case, in-home tests of physical performance may offer a cost-effective alternative to monitoring levels and disparities in objective functional disabilities in highly stratified settings.
The findings from this analysis have at least three policy implications to meet the needs of older, disabled adults in Egypt. First, older Egyptian women have higher objective functional limitation than men, and so have greater real needs for functional assistance. Such assistance may come in the form of simple technologies to improve mobility and functional independence. Such assistance also may be available in families, who normatively are still expected to provide such assistance. However, as women’s schooling attainment and formal work increases, new demands on their time are likely to compete with the real needs of older women (and men) for functional assistance. Thus, surveys of the family members on whom disabled older adults depend would help to quantify potentially growing needs for paid in-home care. Beyond differences in objective functioning, older women also report higher disability, suggesting their potentially greater demands for functional assistance. Potential over-reporting of disability may require educational interventions among older women and men to improve their abilities to assess functional capacities in ways that more closely reflect objective needs for care. Finally, because of gendered socialization, older disabled men may be less likely to report disabilities and to seek assistance for them. Such men may, therefore, be more invisible to the public health infrastructure. For this reason, community outreach and education may be needed at least initially to meet the functional needs of older disabled men.