Introduction
Population aging is considered as serious problem of health and social welfare challenges for all countries in the world (1). The world’s population aged 60 and over will today increase from more than 800 million to two billion by 2050 (2). Prior studies have confirmed that gender differences are generally related to socio-economic and demographic characteristics which contribute to health inequalities in older people (3-5). Although women have a longer life expectancy than men (1); they are more likely to suffer from arthritis, osteoporosis, diabetes, hypertension, physical limitations and multiple chronic diseases which largely make them more dependent on their daily lives (4).
The main objective of this study was to determine the differences in health state among elderly men and women, using a combined framework of socio-economic status and functional impairments.
Materials and Methods
A cross-sectional study was conducted with the approval of the Ethic of the Moroccan health authorities in the region of Marrakech-Safi. A group of 368 older persons aged 60 years and over were selected by a non-probability sampling between March 2017 and June 2018. All participants were selected anonymously and privately through a face-to-face interview. According to the declaration of Helsinki, the study protocol was explained and informed consent was obtained. This declaration includes the fact that participants voluntarily agree to participate after being fully informed of the purpose, methods, risks, and benefits of our study via verbal discussion with study staff, followed by documentation in a written and signed informed consent form.
An interview guide was developed based on the study framework to guarantee that the same questions would be asked of each interviewed participant. This questionnaire includes a list of items relating to socio-economic and demographic characteristics (such as age, sex, marital status, number of children, educational level, previous employment status, income and the degree of perceived family support etc.).
In our survey, a nutritional mini-evaluation-short form (MNA-SF) is used to measure nutritional status (ranging from 0 to 14) (6). This tool includes six questions relating to anthropometric measurements, global assessment (mobility), dietary questionnaire and subjective assessment (neuropsychological problems, food intake). The MNA-SF scale is interpreted as follows: 1) Malnutrition: Zero to seven points, 2) Risk of malnutrition: Eight to 11 points and 3) Normal: Twelve points or greater.
Furthermore, searching health booklets provided all clinical and nutritional information such as functional disabilities and chronic diseases. Hence, the degree of physical disabilities was assessed when a person performed basic activities of daily living. There are six basic activities of daily living including bathing, dressing, feeding, transferring, continence and toileting (7).
In this survey, depressive symptoms were assessed with the 15-item version of the Geriatric Depression scale (GDS-SF), ranging from zero to 15 points: 1) Normal: Zero-five, 2) Moderate depression: Six-ten and 3) Severe depression: 11-15 (8). This scale is a screening tool for depression in the elderly in 15 questions, usually filled between five to seven minutes. Exclusion criteria were participants with dementia, severe neuropsychological disorders and speech impairments.
Statistics
All data were entered into database and analysed using SPSS software (version 16.0, Chicago, IL, USA). Pearson’s c2 test and Fisher’s exact test were used for differences in the percentage of nominal variables. Student’s t-test was used to compare the means of variable. In order to explore gender differences, a multivariate analysis was performed to eliminate the confounders. A p-value less than 0.05, was regarded as statistically significant.
Results
A total of 368 participants were successfully included in this study. The socio-economic levels and demographic characteristics are given in Table 1. Of those interviewed, 45.9% were men and 54.1% were women. Moreover, 52.4% of participants are living in urban areas, 65% are widowed, and 83% are illiterates. Besides, older women complain significantly about illiteracy (78.9%), widowhood (66.8%), lack of health insurance (81.9%), and low income in the past (79.9%) than men counterparts (p≤0.005). The analysis of family characteristics showed that the older women continue to keep up a good relationship with their children (77.88%). Nevertheless, the clinical information and self-reported morbidities are presented in Table 2. The musculoskeletal disorders (38.7%), cardiovascular diseases (37.7%) and the gastrointestinal diseases (24.6%) were significantly the most common morbidities in older women (p<0.05). In addition, edentulism, visual, metabolic, kidney and respiratory diseases are gradually identified in elderly men and women without significant differences (p>0.05). Besides, there were statistically no significant differences between the elderly women and men on malnutrition status (p=0.364).
Furthermore, to screen the depressive symptoms, the GDF-SF: short form was performed. We found that severe depression was significantly observed among elderly women compared to men counterparts (p=0.030).
In Table 3, the multiple logistic regression model displayed that marital status 0.257 (95% CI: 0.140-0.472), previous occupation level 0.242 (95% CI: 0.152-0.384), number of children 0.399(95% CI: 0.212-0.753), musculoskeletal disorders 2.446 (95% CI: 1.372-4.359), and gastrointestinal diseases 2.856 (95% CI: 1.392-5.862) were relatively independent predictive variables associated with older women.
Discussion
This present cross-sectional is one of the few studies among elderly people in Morocco. Regarding the socio-economic status, older women were significantly more likely than men to have low previous occupational status (79.9%) or to live in low-income families, to be widowed or single (66.8%), to be illiterates (78.9%) and to rely financially on their children (74.87%). These findings have been corroborated by earlier studies conducted in low- and middle-income countries (9,10). Hence, similar studies found that illiteracy was higher among women than men counterparts (9,10). Given this trend, the gender gap in education might significantly decrease in the future for older people, as a result, both of the improvements in the general level of education and of an increase in enrolment of Moroccan girls. Moreover, earlier studies have shown that older women are more likely to live alone, single or widowed in developing countries (5,11,12). In fact, these gender differences can be attributed to remarriage tendencies observed particularly among older men in developing countries. As a consequence, older women often refused to remarry, because they fear social pressure, public judgment, insults and even humiliation from the community (5).
In this study, interviewed women continue to come up an affective relationship with their children and even relatives. Building on numerous prior studies and reports, many elders lost their income and remain dependent financially and socially on their children and even relatives (11,13). Moreover, other studies have also revealed that poor socio-economic status and illiteracy are the negative determinants associated with older women in developing countries (9,14). In Morocco, the homemaker position of women could explain their poor socio-economic status, their low outdoor physical activity and their financial dependence on their relatives.
In this investigation, the most elders suffered from multiple chronic diseases, functional disabilities and malnutrition with no significant difference between women and men, but considerably with a higher prevalence of depressive symptoms, gastrointestinal and musculoskeletal diseases in women, being the most disadvantaged. Similar findings displayed that elderly people are mostly suffering from chronic conditions, functional impairments and depressive symptoms (1,14,15). In addition, the musculoskeletal, cardiovascular, gastrointestinal diseases, depression and dehydrations were strongly the most important co-morbidities appeared among older people. Besides, previous studies have shown the same results in Lebanon and the Middle East as a whole (13,16). Furthermore, earlier studies have described that older women have significantly higher prevalence of diabetes, hypertension, arthritis, osteoporosis, migraine, autoimmune and musculoskeletal diseases than men counterparts (1,13,16-19). In analogous studies, the higher prevalence of musculoskeletal disorders in the elderly women can be explained by their painful household activities and their higher prevalence of overweight and obesity (20,21) Likewise, a relationship has been observed between musculoskeletal diseases and negative determinants of health, such as overweight, low education, poor health, and sedentary lifestyle (21,22). In contrast, empirical research has shown that older women, who tend to have multiple chronic conditions rather than fatal, have a longer life expectancy than their male counterparts (1).
Furthermore, the results from the binary logistic regression analysis demonstrated that gastrointestinal diseases were significantly recognized in elderly women and were not intrinsically different from those which occur in men. Besides, other studies have found that women are more likely to suffer from constipation, bloating, swollen belly, tight clothing, irritable bowel, rectocele and asthenia (23,24). In addition, Rectocele syndrome was often due to advanced age, multiparty, vaginal delivery, pelvic surgery and other conditions which are increasing intra-abdominal pressure such as obesity and constipation in elderly women (25).
Regarding depressive symptoms recognized as a public health problem commonly identified in the elderly, our study found that 19.6% of older women had significantly some degree of severe depression. This burden is often combined with poor self-rated health and low socio-economic status which can negatively affect successful aging in Morocco. Similarly, empirical studies have shown older women are considerably more likely to develop severe depression than men counterparts (26-29). As a result, the women psychological traumatism are possibly related to complex interactions including, poor socio-economic status, low education level, reduced daily activity, poor health state, neurobiological changes and stressful life events (13,15).
Study Limitations
Our study limitations included that further investigations among the elderly people should be conducted in other Moroccan regions in order to provide additional information. In addition, a high-quality of dialogue between all participants will be recommended for a better management of successful aging in Morocco.
Conclusion
Chronic diseases and depressive symptoms were common concerns in elderly people. As a result, we suggest that special attention and comprehensive clinical evaluations should be carried out, particularly in elderly women suffering from depressive symptoms and multiple chronic diseases. Therefore, our findings have demonstrated the need for an integrated national framework to analyse the impact of socio-economic and demographic factors on women’s health status as a basis for developing policies and interventions in Morocco.
Acknowledgements
The authors thank the participants of this study. Special thanks go to Mr. Rahhou Lhoussin for his invaluable help in writing this article.
Ethics
Ethics Committee Approval: This study was conducted with the approval of the Ethic of the health authorities in the Region of Marrakech-Safi.
Informed Consent: Informed consent was obtained.
Peer-review: Internally peer-reviewed.
Authorship Contributions
Concept: A.B., A.H., M.C., Design: A.B., A.H., M.C., Data Collection or Processing: A.B., A.H., M.C., Analysis or Interpretation: A.B., A.H., R.A.A., E.K., M.C., Literature Search: A.B., A.H., R.A.A., M.C., Writing: A.B., A.H., M.C.
Conflict of Interest: Authors have declared no conflicts of interest.
Financial Disclosure: The authors declared that this study received no financial support.