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Interactions Between Socioeconomic Status and Living Arrangements in Predicting Gender-Specific Health Status Among the Elderly in Cameroon

Barthélémy Kuate-Defo

INTRODUCTION

The most influential factor historically in the aging of human populations has been fertility reductions. All populations with declining fertility become older, and the speed of aging increases as mortality declines. For the first time in history, many societies in Africa now have the opportunity to age. Accompanying this broad demographic process, however, are other changes—shifting disease patterns and emerging health threats, macroeconomic strains, emergent technologies, changing work patterns and social norms, and cultural practices within and between societies. These dramatic changes in fertility responses and unprecedented mortality reductions in Africa since the 1950s ensure that the population of this continent is bound to age quite rapidly half a century later.

The secular decline in fertility rates historically has been shown to be the most important factor of population aging, via a sustained increase in the ratio of older to younger people. The fall of mortality rates from a combination of advances in public health (e.g., immunization campaigns), medical technology, and standard of living (e.g., better nutrition) has resulted in improvements in life expectancy. Recent estimates suggest that the aggregate proportions of the elderly population in sub-Saharan Africa will grow rather modestly as a result of continued high fertility in many countries, but the size of the elderly population is expected to increase by 50 percent, from 19.3 to 28.9 million people from 2000 to 2015 (National Research Council, 2001).

These fertility and unprecedented mortality reductions, along with de-



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9 Interactions Between Socioeconomic Status and Living Arrangements in Predicting Gender-Specific Health Status Among the Elderly in Cameroon Barthélémy Kuate-Defo INTRODUCTION The most influential factor historically in the aging of human popula- tions has been fertility reductions. All populations with declining fertility become older, and the speed of aging increases as mortality declines. For the first time in history, many societies in Africa now have the opportunity to age. Accompanying this broad demographic process, however, are other changes—shifting disease patterns and emerging health threats, macroeco- nomic strains, emergent technologies, changing work patterns and social norms, and cultural practices within and between societies. These dramatic changes in fertility responses and unprecedented mortality reductions in Africa since the 1950s ensure that the population of this continent is bound to age quite rapidly half a century later. The secular decline in fertility rates historically has been shown to be the most important factor of population aging, via a sustained increase in the ratio of older to younger people. The fall of mortality rates from a combination of advances in public health (e.g., immunization campaigns), medical technology, and standard of living (e.g., better nutrition) has re- sulted in improvements in life expectancy. Recent estimates suggest that the aggregate proportions of the elderly population in sub-Saharan Africa will grow rather modestly as a result of continued high fertility in many coun- tries, but the size of the elderly population is expected to increase by 50 percent, from 19.3 to 28.9 million people from 2000 to 2015 (National Research Council, 2001). These fertility and unprecedented mortality reductions, along with de- 276

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277 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON clines in deaths from infections and parasitic diseases, have resulted in in- creases in life expectancy throughout the world, leading to increasing num- bers and proportions of elderly people. This demo-epidemiological transi- tion has been attributed to public health measures, advances in medical science, and health care. Irrespective of reasons, people are living longer and many of them are having more years of healthy, active, and indepen- dent life, especially in developed countries. In contrast, there is a dearth of information and research on the health status and functional limitations of the older populations of many develop- ing countries in general (Gorman, 2002; National Research Council, 2001; Palloni, Pinto-Aguirre, and Pelaez, 2002; Restrepo and Rozental, 1994) and notably in African countries. In this region of the world, population aging coincides with increasing social inequalities, poverty, unemployment, vio- lence, malnutrition, and the devastating and differentiated effects of the rampant HIV/AIDS epidemic on individuals, families, communities, and nations. The causes and consequences of aging in this region within and be- tween countries are complex, multifactorial, and intertwined. Their study is difficult and demands an interdisciplinary approach, given the complexity of the interactions among social, economic, and environmental variables and their effect on health status and functional limitations. The projected increase in the number of older people poses new challenges to researchers, policy makers, and planners. This paper addresses the following questions: Is the population in Africa living healthier, longer lives or are added years accompanied by disabilities and generally poor health? How do changing family structures and socioeconomic conditions affect the prevalence of poor health and limited activity among the elderly? Since current and prospective policy responses are likely to differ among countries in Africa, a number of natural experiments are needed to enable countries to learn from each other’s experiences. This study examines self- reported health and physical functional status among older people in a tran- sitional environment—the rural and semirural societies of Cameroon—and compares their determinants in men and women. Such an investigation is important as a contrast to the general tendency to focus on urban areas of less developed countries and sub-Saharan Africa. Although differences in health between the richest and the poorest segments of the populations in many societies are clearly identifiable, differences among the rural, semirural, and urban areas of Africa may not be so obvious. In addition to variations in life expectancy, population health, and adult mortality, self- ratings of poor health and disability are likely to be lower in semirural areas than in most urban settings, and the average rate of self-reporting of good health and functional status is usually lower in rural than in urban areas. Furthermore, some differences in social influences (e.g., education, social

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278 AGING IN SUB-SAHARAN AFRICA norms and practices) on perceived health among urban, semirural, and ru- ral dwellers are most likely to be present. With no study to my knowledge in Africa that has focused simulta- neously on the health and functional status of rural and semirural segments of the elderly, research in this area is needed. There is a growing consensus among public health researchers and policy makers that more information is required on the mechanisms that produce gender differences in health outcomes in different social settings (Arber and Ginn, 1993; MacIntyre, Hunt, and Sweeting, 1996). This study explores the health differences be- tween older women and men living in 75 urban and rural localities of Cameroon, with the ultimate aim of extending the information and knowl- edge base to prevent social exclusion and promote the health of older women and men in Africa. This paper seeks to examine the extent and nature of gender inequalities in health in later life and the extent to which these inequalities can be explained by differences in socioeconomic charac- teristics and the living arrangements of older women and men. The ultimate goal is to provide local health researchers, professionals, and community organizations with information needed to plan gender-sensitive interven- tions to promote the health and quality of life of older women and men. More specifically, I consider the following research questions: 1. What explains gender differences in health and functional status among older people? 2. By what mechanisms and to what extent do high socioeconomic sta- tus and better living arrangements lead to better health and functional status? 3. To what extent and by what mechanisms are the effects of socioeco- nomic status and living arrangements on health and functional status of older people dependent on gender? There are several plausible ways in which certain aspects of gender inequality, socioeconomic status, and living arrangements may influence health and functional status at older ages. For many of these influences, however, empirical studies are lacking that can confirm the importance of particular intermediate variables. The socioeconomic status and living ar- rangements of older women and men and their possible connections with health and disability may be understood only in particular sociocultural contexts, given the relative position of women and men in different societ- ies (Anker, Buvinic, and Youssef, 1983). This is because indicators of so- cioeconomic status and living arrangements tend to be heavily context- dependent and also because particular aspects of female versus male status may have contradictory effects on health and disability in different socio- cultural contexts.

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279 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON This paper is devoted to the centrality of health and functional status by focusing on gender, socioeconomic status, and living arrangement differ- entials in informing health, social, and economic policy formulation. The first section presents the data and methods used for analysis. The next sec- tion presents the results. The final section summarizes the main findings and discusses their implications. DATA AND METHODS OF ANALYSIS The Data The study uses data from the first round of the Cameroon Family Life and Health Survey (CFHS), conducted in 1996-1997. This is a survey of representative and randomly selected individuals age 10 and older in 75 urban and rural localities in Cameroon. Each locality uses probability samples in which all households with individuals age 10 and older have a nonzero chance of inclusion, designed to produce comparable locality-level estimates for the population under study. The CFHS employs a self-weighted proportional sampling design, with the proportions of randomly sampled households in all 75 localities forming the Bandjoun region in the sample equal to the same proportions in the general population. The sample was drawn so as to be representative in each of the following age- and sex- specific groups: adolescent boys ages 10-19, adolescent girls ages 10-19, men ages 20-49, women ages 20-49, men age 50 and above, and women age 50 and above. After a household has been selected, one individual among all respondents in that household was randomly selected and inter- viewed until the sample size required for a given locality was attained. A total sample of 2,381 individuals was interviewed, of whom 631 were age 50 and older. Further details regarding sampling methodology and the sur- vey have been published elsewhere (Kuate-Defo, 1998, 2005; Kuate-Defo and Lepage, 1997). The postulated risk and protective factors used in this study are presented in Table 9-1. The survey was carried out in the prefecture of Bandjoun, in the west- ern part of Cameroon. This area is representative of the system of beliefs, customs, and social structure of the population of Cameroon. In an area of approximately 274 sq km, this region combines the features of a highly modernized environment with a typical traditional Cameroonian society. The urban and semiurban localities of Bandjoun have one of the country’s universities, three public hospitals, two private hospitals in operation since the early 1950s, about a dozen public health centers, several traditional healers attracting people from various social strata, several high schools and professional schools, infrastructures for communication and transpor- tation, and entertainment sites. In the rural areas, there are over 70 tradi-

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280 TABLE 9-1 Sample Proportions of People Age 50 and Older in the Cameroon Family Life and Health Survey, 1996-1997 Total Sample (N = 613) Men (N = 270) Women (N = 343) Variables N % N % N % Outcome Variables Self-Rated Health Excellent/very good/good/fair 474 77.3 227 84.1 247 72.0 Poor 139 22.7 43 15.9 96 28.0 Physical Functional Limitations No 309 50.4 167 61.9 142 41.4 Yes 304 49.6 103 38.1 201 58.6 Poor Health and Functional Limitations No 506 82.5 238 88.1 268 78.1 Yes 107 17.5 32 11.9 75 21.9 Exposure Variables Gender Female 343 56.0 — — — — Male 270 44.0 — — — — Level of Education None 452 73.7 133 49.3 319 93.0 Some education 161 26.3 137 50.7 24 7.0

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Economic Activity Status Paid work 162 26.4 108 40.0 54 15.7 Unpaid work 111 18.1 54 20.0 57 16.6 Retired/at home 253 41.3 70 25.9 183 53.4 Unemployed 87 14.2 38 14.1 49 14.3 Marital Status Single/widowed/divorced 218 35.6 31 11.5 187 54.5 Married polygamous 211 34.4 109 40.4 102 29.8 Married monogamous 184 30.0 130 48.1 54 15.7 Age at First Marriage (continuous variable) Mean = 23.2 SD = 8.68 Mean= 29.15 SD = 9.26 Mean = 18.33 SD = 3.71 Kinship Size Less than 6 348 56.8 150 55.6 198 57.7 6 or more 265 43.2 120 44.4 145 42.3 Age Cohort (in years) 50-64 301 49.1 128 47.4 173 50.4 65-74 196 32.0 90 33.3 106 30.9 75-96 116 18.9 52 19.3 64 18.7 Main Region of Residence Djaa/Pete/Yom 213 34.7 135 39.4 78 28.9 Djiomghouo/Famleng/Tsela 129 21.0 72 21.0 57 21.1 Demdeng/Sedembom/Haa 164 26.8 88 25.7 76 28.1 Tsela/Famla II/Bagang Fodji 107 17.5 48 14.0 59 21.9 281

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282 AGING IN SUB-SAHARAN AFRICA tional chiefdoms with traditional authorities and practices, an extensive practice of polygamy and other gender-related practices, agricultural pro- duction, and extensive farming. The geographical distribution of the popu- lation reflects one of the highest population densities (a population of over 120,000 inhabitants, thus a density of about 438 inhabitants per sq km) and the highest fertility levels (a total fertility rate close to 7) in the country. The entire region is accessible in all seasons of the year. Measurements of Self-Rated Health and Functional Limitations In this study, self-rated health was assessed among 631 individuals re- siding in 75 urban and rural localities in Cameroon, through a question asked about perceived general health: “Would you say that in general your health is: Excellent, Very Good, Good, Fair, or Poor?” From this item, the study used a dichotomous outcome measure coded 1 if poor and 0 if excel- lent, very good, good, or fair. Thus, health status for all persons age 50 or older is based on an overall assessment of individual health on a 5-point scale (5 = very good, 4 = quite good, 3 = average, 2 = quite poor, 1= poor). This measure is one of the most frequently used health status measures in population-based epidemiological research and has been a powerful pre- dictor of morbidity and mortality. It has been demonstrated in previous studies that the reliability of self-rated health has been as good as or even better than that of the multiitem health scales. A review of 27 community studies concluded that even such a simple global assessment appears to have high predictive validity for mortality, independent of other medical, behavioral, or psychosocial risk factors (Idler and Benyamini, 1997). Sev- eral subsequent studies have also demonstrated the usefulness of capturing the health status of the elderly persons and their determinants by focusing on such a simple operational measure of health. For most studies, odds ratios for subsequent mortality ranged from 1.5 to 3.0 among individuals reporting poor health compared with those reporting excellent health. Self-reported health has been demonstrated in longitudinal studies to predict the onset of physical disability and functional or activity limitations (Farmer and Ferraro, 1997; Ferraro, Farmer, and Wybraniec, 1997; Idler and Benyamini, 1997; Idler and Kasl, 1995; Mor et al., 1989; Wilcox, Kasl, and Idler, 1996). While the majority of the elderly are capable of maintain- ing their autonomy, a sizeable proportion increasing at each age becomes frail and in need of support and care at home or in institutions. I consider a dependent variable measuring the coexistence of poor health and disability. I do so because not all of those who are ill have func- tional limitations, and vice versa. What is important is the ability to cope with daily life in spite of chronic morbidity and the degree to which the

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283 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON elderly may need assistance to continue to do this even at decreased levels of activity. Such functional activity is widely measured by indices of activities of daily living. In this study, functional status was measured among 631 indi- viduals age 50 and over by asking the following questions: “Do you have any activity limitation in fulfilling your activities of daily life? If yes, what is the nature of that limitation? Is the limitation in activity at home, at work, elsewhere, and during leisure/travel?” From answers to these three ques- tions, the researchers created a dichotomous outcome measure coded 1 if any functional limitation was reported and 0 otherwise. We also created a third outcome variable measuring the simultaneous reporting of poor health and functional limitations coded 1 if an elderly person reported as being in poor health also had a limitation in activity and 0 otherwise. Methods of Analysis The methods of data analysis in this paper include the description of variables, followed by an examination of the association between each risk or protective factor and the three outcome variables (bivariate analyses), as well as the study of the interrelationships between the different risk or pro- tective factors in predicting the outcomes (multivariate analyses). Since the primary goal is to evaluate the effect of a postulated risk or protective fac- tor on each outcome, I investigate what this effect is before and after con- trolling for other factors so as to determine whether such an effect is direct or mediated through other postulated risk or protective factors. A mediat- ing factor is a link in the causal chain leading from the postulated risk factor to the outcome and is partly determined by that risk factor. To illustrate the general strategy, consider three postulated risk factors (V1, V2, and V3) of poor health or disability (or both) among older people. The overall effect of each risk factor (or group of risk factors) V1 is evalu- ated first (Model A). In the second step, another putative factor or a set of factors V2 is added (Model B) and its effect assessed in the presence of V1, which would then constitute a proper confounding factor. The unconfounded effect of V2 would then be obtained from this equation. The magnitude of the remaining effect of V1 in Model B would reflect only the part that is not mediated through V2. Model B is then extended to add another postulated risk factor V3 in Model C and its effect assessed in the presence of both confounding variables, V1 and V2. Any residual effect of V1 would be the part that is not mediated through either V2 or V3. Simi- larly, any residual effect of V2 would not be mediated through V3. In inter- preting the results, it is worth noting that some if not most of the effect of V1 will be captured by the other two factors (V2 and V3). It would be incorrect to interpret that V1 has no effect after adjustment for confound-

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284 AGING IN SUB-SAHARAN AFRICA ing variables, since in Model C the overall effect of V1 will be underesti- mated due to the presence of mediating factors. The strategy may be ex- tended to situations with several variables in each hierarchical level of model building. I use general health status and physical functional status and not more refined cause-specific or level of severity measures because differences in reporting of such fine-tuned measures can obscure underlying events by misclassifying outcomes. Empirically, we measure socioeconomic status us- ing two indicators given their pertinence in the study context: level of edu- cational attainment and economic activity status. Living arrangements are empirically assessed using three indicators: marital status by type of union, timing of first marriage in the life cycle, and family size support network. The effects of gender, socioeconomic status, and living arrangements on self-reported health and physical functional limitations are estimated with logistic regression models. The general logistic regression model used can be described as follows: Yi = a + bXi +JZi + lWi + hCi where Yi is the value of individual i on the outcome Y. Since all three out- comes considered in this study are dichotomous (i.e., poor health, func- tional limitations, poor health with functional limitations), Yi equals the logit (or log-odds), a the overall constant or intercept, Xi the value of the gender of individual i and b the vector of gender effects, Zi the vector of socioeconomic status indicators and ϑ the vector of associated param- eters, Wi the vector of living arrangements factors and l its vector of pa- rameters, and Ci the vector of control variables and h the vector of their corresponding parameters. These models estimate the odds ratios of poor health (versus excellent/very good/good/fair health), functional limitations, and poor health with functional limitations, according to gender and vari- ous indicators of socioeconomic status and living arrangements. I use this common statistical technique for studying dichotomous outcomes, which assumes that, for all individuals in the sample, these outcomes are indepen- dent. This procedure is appropriate because in the 1996-1997 CFHS sur- vey, only one person per household was included in the sample, so that outcomes for family or household members are not correlated, and there is no room for the health or functional status of one unit in the sample to be dependent on attributes shared by other members, such as sanitary condi- tions in the household. Thus, the single-level regression models fitted here correctly ignore any hierarchical data structure and produce correct stan- dard errors, so that the effects of factors associated with poor health and disability in the elderly cannot appear significant when in fact they are not.

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285 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON Thus, one attractive feature of the CFHS-1996-1997 is that the survey data are self-weighted. RESULTS Descriptive Analyses The sample consisted of 631 individuals age 50 years and over (44 percent men, 56 percent women) and 319 individuals age 65 and over (45.8 percent men, 54.2 percent women). Perceived health was missed in just 16 (2.5 percent) individuals age 50 or older and 6 (1.9 percent) indi- viduals age 65 or older, and functional limitations were missed in 14 (2.2 percent) individuals age 50 or older and 5 (1.6 percent) individuals age 65 or older. The rest of the analyses focuses on individuals age 50 years and over, unless otherwise stated. Gender-specific sample characteristics are shown in Table 9-1. Overall, 22.7 percent of individuals reported their health as being poor, 49.6 percent reported limitations in activity, and 17.5 percent reported having both poor health and functional limitations. Of the 304 individuals who reported limitations, 164 (26 percent) reported being limited in activ- ity at home, 231 (36.6 percent) reported being limited in activity at work, 46 (7.3 percent) reported being limited in activity outside the home, and 194 (30.7 percent) reported having functional limitations for leisure or travel activities. The two socioeconomic status variables considered in the analyses show important gender disparities. Overall, the level of education of this semirural population is quite low, and 73.7 percent of the sample is illiterate. These data indicate that the numbers and proportions of people who are unem- ployed or retired are highest among the elderly. The female disadvantage among the elderly is sizeable, since fully 93 percent of older women have no education compared with almost half of older men. Similarly, unemploy- ment is substantially higher for women than for men, and fully 60 percent of men age 50 and over are still working outside the home. But one must keep in mind that most women who reported being “at home” are actually farmers, notably in typical rural and periurban areas of Africa and western Cameroon. Hence, they are probably responsible for providing food and material resources to their family through the output of their agricultural labor. The three variables capturing living arrangements in the elderly also depict important differences by gender. About one-third of the sample is married monogamous, married polygamous, or single/widowed/divorced, respectively. When analyses are separated by gender, the proportion of older women who are widowed (the main category in the single/widowed/di-

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286 AGING IN SUB-SAHARAN AFRICA vorced group) is almost five times higher than the proportion of their male counterparts. In contrast, the proportion of older women who are married monogamous (15.7 percent) is only about one-third the proportion of older men in monogamous marriages (48.1 percent). The pattern of age at mar- riage behaves as expected, with older women being married quite young compared with older men. Irrespective of gender, there is stability in the sample proportions for kinship size (roughly 42-44 percent of the sample having at least six persons in their kinship network). The age distribution shows that almost half of the sample analyzed is between ages 50 and 65, and only 19 percent of respondents are age 75 and over; the oldest person in the sample was 96 years old. The sample propor- tions by gender show no differences worthy of notice. The distribution of respondents by region of residence indicates that about one-third of the sample lives in the urban or semiurban areas of Djaa, Pete, and Yom. The urban regions are considered as the reference category in the analyses, and there are slightly more older men (39.4 percent) than women (28.9 percent) in urban centers. Differentials by Health and Functional Status of the Elderly Table 9-2 displays the significance of the differences in the percentages of respondents reporting poor health, functional limitations, and both poor health and functional limitations. Notwithstanding a few nonsignificant differences in kinship size and region of residence, all other differences in postulated risk and protective factors of poor health and activity limitations are statistically significant. In particular, these bivariate analyses show that significantly higher pro- portions of female respondents report being in poor health, having func- tional limitations, or both than male respondents. Higher percentages of older respondents with no education report poor health, functional limita- tions, or both, than their educated counterparts. These differences are sta- tistically significant for all outcomes, except that the results for older women with functional limitations do not vary with educational attainment. In gen- eral, older persons who are retired or who stay at home and to some extent those who are unemployed report significantly more poor health, activity limitations, or both than their counterparts who are in the labor force. Single, widowed, or divorced elderly people tend to report significantly more poor health and functional limitations than those in monogamous marriages, and women tend to be at a disadvantage compared with men. Significantly higher proportions of older persons who are in polygamous marriages report poor health (20.4 percent), functional limitations (51.7 percent), or both (16.6 percent) than older people married in monogamous unions (13.6, 38.6, and 10.3 percent, respectively). A similar pattern is de-

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303 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON Model 4 Model 5 Model 6 Model 7 Men Women Men Women Men Women Men Women 1.00 1.00 1.00 1.00 1.00 1.00 0.76 0.44 0.63 0.37 0.80 0.42 0.54 0.50 0.58 0.49 0.68 0.50 1.28 1.53 1.42 1.62 1.49 1.52 1.00 1.00 1.00 1.00 1.00 1.00 2.17 1.48 1.47 1.57 1.75 1.22 1.72 1.16 1.69 1.09 1.68 0.96 1.00 1.00 1.00 1.00 1.00 1.00 1.24 1.56¶ 1.29 1.60¶ 1.26 1.54¶ 1.00 1.00 1.00 1.00 1.00 1.00 0.34§ 1.20 0.34§ 1.20 0.35§ 1.13 0.46§ 0.49§ 0.46§ 0.48§ 0.55§ 0.53§ 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.45 0.75 0.38 0.70 0.40 0.75 1.36 0.94 1.23 0.96 1.29 0.94 0.56 0.49 0.45 0.44¶ 0.50 0.50 180.92 333.37 176.00 342.98 179.72 336.86 172.90 329.91 15.62 26.92 20.54 17.31 16.82 23.43 23.64 30.38 (7) (7) (8) (8) (7) (7) (11) (11) by various controls, but the regional disparities noted in previous models are somewhat attenuated. As in previous models, the younger the age at first marriage, the higher the odds of reporting poor health with functional limitations (Models 8 and 11, Table 9-5a) but the significance of such a relationship is largely re- stricted to older women (Models 2 and 5-7, Table 9-5b). Since early mar- riage is associated with high fertility, which in turn is strongly correlated with short birth intervals in highly fertile populations, such as those of western Cameroon, it is likely that the effects of age at marriage on poor health and functional limitations at older ages operate through the parity

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304 AGING IN SUB-SAHARAN AFRICA effect and maternal depletion syndrome, which has been well documented in the literature on women’s health in Cameroon and elsewhere (Kuate- Defo, 1997). Kinship size appears to have a protective effect on older men but not on older women. The larger the kinship size, the lower the odds of reporting being in poor health with activity limitations among older men: those with kinship size of six or more are at least three times less likely to report these conditions than those with kinship size under six (Models 2 and 5-7, Table 9-5b). The odds ratios of poor health with activity limitations increase with age, even after all other postulated risk and protective factors are taken into account. Irrespective of gender, there is strong evidence that the younger the generation, the lower the odds of being in poor health with functional limitations, even after all controls are introduced in models for men and women (p < 0.05, Model 7, Table 9-5b). Therefore, functional limitations explain the age-health relationship found above, but age appears to have a direct relationship with the combination of poor health and functional limi- tations for the elderly in western Cameroon. Finally, when they are present, regional differences in poor health with functional limitations appear to show a disadvantage for urban and semiurban residents (Models 4-6 and 9, Table 9-5a), but after all controls are introduced, only residents of Tsela, Famla II, and Bagang Fodji have some significant advantage vis-à-vis those from Pete, Djaa, and Yom. When the analyses are separated by gender, only older women from Tsela, Famla II, and Bagang Fodji are at an advantage (Models 3 and 5, Table 9-5b), which is purged by controls for socioeconomic status. Hence, it is likely that regional differences in poor health with activity limitations are largely explained by differences in the socioeconomic context of each region. There is evidence that gender differences in poor health with activity limitations are present but are fully captured by differences in the socio- economic standing of older men versus women. The influences of socio- economic status on poor health and functional limitations are mediated at least partly through age and the socioeconomic context of communities of residence. The disadvantage associated with widowhood is unaltered, and gender inequality explains the deleterious effects of living in polygamous unions on self-assessed health and functional status. Age at first marriage is strongly associated with poor health with functional limitations among older women, and the age effects remain unaffected by controls for other covariates. Older men who belong to a larger kinship are less likely to report poor health with functional limitations. Poor health with functional limitations increases with age, even after controlling for all postulated risk and protective factors, and this finding applies to both older men and women. Finally, only older women who are residents of Tsela, Famla II,

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305 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON and Bagang Fodji have some significant advantage vis-à-vis those from Pete, Djaa, and Yom, and socioeconomic standing explains their relative advantage. The data also show that residing in the Tsela, Famla II, and Bagang Fodji neighborhoods is associated with decreased odds of poor health of 45 to 55 percent, compared with living in the highest develop- ment localities of Djaa, Pete, and Yom. Similar findings emerge concerning functional limitations. Together, these results suggest that living in urban areas may not be sufficient to provide better health status in contexts simi- lar to the study sites investigated. SUMMARY AND DISCUSSION This study has demonstrated that it is possible to lengthen life expect- ancy while maintaining the quality of life in Africa. The results extend pre- vious findings on the health advantages stemming from socioeconomic sta- tus and living arrangements to semirural areas of Africa. These factors appear to exert independent effects on self-rated health and functional limi- tations in most instances. Overall, there are significant interactions among gender, socioeconomic status, and living arrangements in predicting poor health, functional limitations, or both. A number of interactions were tested in models for the total sample as well as gender-specific models, but none reached significance levels. However, after adjusting for all other measured covariates, the models fail to show significant interactions of several mea- sures of socioeconomic status and living arrangements in predicting poor health and disability, but that does not mean that such links are nonexist- ent. For example, it is likely that decisions about work, retirement, and unemployment are not independent of considerations of living arrangements for the elderly, just as it is the case for younger age groups. The effects of socioeconomic status on perceived health were quite simi- lar among men and women. Although a robust relationship between educa- tion and health status has been demonstrated in previous research (for a review, see Robert, 1999), the processes that explain the link are not well understood, especially in developing countries (Zimmer, Liu, Hermalin, and Chuang, 1998). This study advances such understanding in two notable ways. First, the study found differences in the relationship of education and self-rated health and education and functional limitations among older people. Second, it found that gender inequality entirely explains the educa- tion differences in self-rated health. The importance of socioeconomic differences in health status is well documented in the health literature, and this study provides empirical evi- dence on the robustness of these differences in the African context. Related to diversity is the fact that the health of elderly populations in all countries varies according to socioeconomic position (National Research Council,

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306 AGING IN SUB-SAHARAN AFRICA 2001). The magnitude of these differences, as well as their causes, varies over time within and among societies. To develop policies effectively, one must have an understanding of these causes, which in turn requires a fuller understanding of the determinants of socioeconomic differences in health and functioning. Policy responses to such differences will ideally cover a wide range of determinants, including the provision of, access to, and response to medical care and social services. Therefore, an underlying need in any research agenda is to include a link to socioeconomic position in the collection of population and health data on elderly individuals. Economic activity status captures the extent to which an older person is unemployed, working, retired, or housewife. In the mul- tivariate analyses, work was measured broadly to include both paid and unpaid work. As life expectancy increases, the postretirement life period is expected to get longer; greater health and other needs demand appropriate income for the elderly, who may increasingly be forced to compete in the labor market against younger, more skilled, and highly educated people in order to secure an income. This study confirms that the aging population that is unemployed or retired is numerically and proportionally more important as it grows older, as previous studies have found (e.g., Møller and Devey, 2003). Statistically significant differences in self-rated health by level of education are entirely explained by gender inequality, which is likely to operate in turn through the income or wages advantage of men compared with women. Evidence of gender differences in self-rated health has been inconsis- tent, with a male advantage reported in some studies (Gijsbers van Wijk, van Vliet, Kolk, and Everaerd, 1991; Rahman, Strauss, Gertler, Ashley, and Fox, 1994; Zimmer, Natividad, Lin, and Chayovan, 2000), but no advan- tage in others (Jylhä, Guralnik, Ferrucci, Jokela, and Heikkinen, 1998; Leinonen, Heikkinen, and Jyhhä, 1998; McDonough and Walters, 2001; Zimmer et al., 2000). The evidence from developing measures to test these conjectures remains very limited. Even if measures of self-rated health were reliable and comparable across populations, empirical evidence is likely to be greatly influenced by the cultural and social norms and practices as well as power relations in specific socioeconomic environments. This study has found that older men are indeed at an advantage com- pared with older women (odds ratio of 0.49, p < 0.05), but that these gen- der differences in self-rated health in favor of men in Cameroon are entirely explained by the health advantage conferred by their labor force and eco- nomic activity status (see Models 1, 3, and 7, Table 9-3a). Similarly, older women tend to report being in poor health with functional limitations more than men, but the female disadvantage again is entirely explained by differ- ences in their socioeconomic status relative to older men. It has been sug-

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307 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON gested that respondents draw on a number of sources when they make their self-assessment of health, including family history, severity of current ill- ness, possible symptoms of diseases not yet diagnosed, trajectory of health status over time, as well as the availability of external resources (e.g., social support) and internal resources (e.g., perceived control) (Idler and Benjamini, 1997). The findings indicate that irrespective of such sources, gender inequality in health status necessarily operates through a rise in so- cioeconomic status in Cameroon. One of the most important findings of this study is that the younger the age at first marriage of an older woman, the higher her odds of reporting being in poor health (Models 2, 5, 6, and 7, Table 9-3b) and having func- tional limitations (Models 2, 5, 6, and 7, Table 9-4b) as well as the combi- nation of poor health with functional limitations (Models 2, 5, 6, and 7, Table 9-5b), even after all postulated covariates are included in the models. In contrast, age at marriage has a trivial effect on older men’s health and functional status. Since early marriage is associated with high fertility, which in turn is strongly correlated with short birth intervals, it is likely that the effects of age at marriage on poor health and functional limitations at older ages operate through the maternal depletion syndrome, which has been well documented in the literature on women’s health in Cameroon (Kuate- Defo, 1997). This finding is also consistent with previous studies, which have dem- onstrated a relationship between early life conditions and later health and survival (Alter, Oris, Neven, and Broström, 2002; Conde-Agudelo and Belizan, 2000; King, 2003; Lundberg, 1993; Mosley and Gray, 1993). Be- cause early marriage is strongly associated with high fertility and repro- ductive health problems, these robust findings suggest that women’s issues in the areas of child marriage and childbearing are of paramount impor- tance. This concerns the promotion of reproductive health in young girls and their successful transition to adulthood, as well as throughout the life cycle and especially in considering social and health policies for the elderly population. Indeed, Bledsoe (2002) shows that, in rural Gambia, women view aging as contingent on the cumulative physical, social, and spiritual hardships of personal history, especially obstetric trauma. It is likely that such ill health and disability during old age among women are a result of exacerbated risks across the life course as they assume their reproductive and productive roles. The fact that early marriage is a robust risk factor for poor health and functional limitations among older women suggests that delaying marriage will have large payoffs not only in the short term, to ensure a successful transition to adulthood for girls, but also in the long term, in protecting the health of women and enhancing their quality of life at older ages. There- fore, there is an urgent need for the international community to address

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308 AGING IN SUB-SAHARAN AFRICA more vigorously the problem of early marriage in developing countries and to go beyond rhetoric, following repeated calls for action made by such organizations as UNICEF (2004) to prevent children from bearing children. The finding that kinship size has a protective effect on the self-rated health of older people (especially men) is also consistent with the finding from a recent study showing that the risk of poor health and mortality is decreased by membership in large patriarchal kin groups (Hammel and Gullickson, 2004). I consider kinship size as a nurturing and enhancement factor in residential patterns that promote health and prevent disability, at least when the older person has some control over the social relations within the kinship. In most African societies the older the men, the stronger their control over familial matters and living arrangements and therefore the big- ger their advantage with a larger kinship. The impact of social relations within the kinship is likely to interact with age in predicting health status. Specifically, the type and nature of social relations within the family con- nections as well as their usefulness will also vary across the lifespan. In contrast to the situation for men, social relations for women are not neces- sarily positive and may not always contribute to improved coping with illness and disability, especially for those who are caregivers and give social support to family members, in the addition to their traditional roles of re- production and production in most societies in Africa. Many researchers have examined the relationship between age and self- reported health, but the evidence is inconsistent (Helweg-Larsen, Kjoller, and Thoning, 2003). About one-third of studies show that older people evaluate their health more positively, another one-third show that the eld- erly evaluate their health more negatively, and one-third show no relation- ship between self-reported health and age. Idler (1993) found in a sample of elderly age 65 and older in the United States that older participants rated their health as better than younger participants at any given level of health status. Idler attributed this result to both a cohort effect (i.e., older cohorts may have different perceptions about what constitutes good health), an age effect (i.e., people evaluate their health differently as they age), and a sur- vival effect (i.e., individuals who evaluate their health positively are more likely to survive). This study shows that younger elderly (under age 65) are significantly less likely to report poor health, before controlling for functional limita- tions (odds ratio of 0.58, p < 0.05). However, when functional limitations are taken into account in the model fitting, the age differences are trivial. Indeed, functional ability is typically highly correlated with self-reported health and declines with age, as expected from biological theory. It has been suggested that if functional ability is not controlled, then self-reported health may appear to decline with age, when in fact this decline can be entirely

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309 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON accounted for by functional ability (Bjorner et al., 1996). The analysis con- firms this conjecture (see Model 13, Table 9-3a, and Model 8, Table 9-3b). The findings of this study allow one to identify opportunities and pri- orities for further research and appropriate interventions. It has been ar- gued that a sounder theoretical basis for socioeconomic classification would yield better understanding of the determinants involved. One approach to this end is to conceive of three different modes of social stratification: one based on degree of material deprivation, one based on social power rela- tions, and one based on general social standing (National Research Coun- cil, 2001). Measures of social deprivation are appropriate for assessing health differences among those living in absolute poverty. Such measures are less appropriate when health follows a social gradient. In such cases, there are clear social inequalities in health among people who are not mate- rially deprived. Other concepts must therefore come into play. A second approach that does not potentially relate to the whole social gradient is based on power relations in the workplace. Occupations are defined in terms of power and autonomy, a perspective that has its origin in the Marxist concept of class. Such a measure is appropriate for social clas- sification among people of working age and less appropriate for those be- yond working age, especially in settings in which aging starts early and the retirement age is 55, as in most sectors of employment in Cameroon until recently. The degree to which occupation continues to provide a reliable indicator of socioeconomic position beyond working age will vary, and additional measures of socioeconomic classification will be needed. This is especially the case for older women, particularly those who are single, wid- owed, or divorced, which is why I explicitly consider marital status as a predictor in the analyses. A third approach—general social standing—has features in common with the concept of status based on patterns of consumption and lifestyle. The status group shares the same level of prestige or esteem and, in addition to common forms of consumption and lifestyle, limits its interactions with members of other groups. This approach fits the typical way of life in semirural Cameroon, where the study’s data come from, given the social organization of the society and interactions by membership groups in terms of adult roles and responsibilities, sociotraditional ranking in the social hi- erarchy, and so forth. Among the most important policy concerns relevant to health and lon- gevity in modern economies are the future fiscal viability of pension, health, and social insurance systems, if any, both public and private, and the impli- cations of these systems for savings and investment rates. How long people continue working, paying taxes, and saving will feature prominently in the consequences of population aging. Many people already work less than half a lifetime because of extended periods of schooling and training in early

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310 AGING IN SUB-SAHARAN AFRICA life, earlier retirement, and enhanced longevity, posing a challenge to the sustainability of systems designed to support older people. In all age groups, but particularly among older people, there is a substantial amount of self- care, as well as varying levels of alternative and complementary health care practices, including self-medication with herbs and the use of alternative practitioners, that may have an impact on health outcomes. These issues also deserve consideration in the context of health research among the eld- erly, but they were beyond the scope of this study. This study suggests that a fuller understanding of the appropriate deter- minants of socioeconomic differences in health and functioning generally requires longitudinal, representative population surveys. Such surveys are essential for establishing causal associations and assessing the magnitude of causes operating in all directions. In other words, longitudinal data are important for determining the degree to which levels of health and func- tioning determine social and economic position, as well as for assessing the magnitude and nature of these determinants of health and functional status. Both personal behaviors and many public health measures bear on health status. Health promotional activities aimed at older persons may or may not involve direct contact with the formal health care system; examples of such activities include education programs and provision of good preven- tive nutrition, safe transportation to enhance mobility, and adequate hous- ing. Effective national and regional policies for health promotion among older people require that important deficits in these areas be identified. Community-based population and health surveys may be the only means of acquiring accurate information on such issues as cigarette and alcohol con- sumption, perceived health status, levels of mobility, and social interaction. Coordination of public and clinic policies relevant to health promotion and disease prevention among the elderly is essential if these policies are to have the desired positive effects on the health status of older people. Again, the most effective means of obtaining the information necessary for such cross- national research is representative household surveys of older people, like the CFHS panel surveys, which so far have been fielded in 140 localities in western and northwestern Cameroon. Because of the higher rates of mor- bidity and disability that occur with increasing age, older people make sub- stantial use of formal health services. Such services consume an enormous amount of resources. Again, cross-national comparative research is one important avenue for addressing this issue by examining international varia- tions in organization, financing, delivery, and evaluation of elder health services. Given the current state of knowledge in African countries, one cannot prevent the majority of the diseases and impairments of old age, but to make a start it is necessary to study the epidemiology of these conditions and measure their risk and protective factors. A further extension of this

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311 GENDER-SPECIFIC HEALTH STATUS AMONG ELDERLY IN CAMEROON study will involve the epidemiology of the specific diseases with increasing prevalence in the elderly populations of Africa, including but not limiting to hypertension. In addition, it would be necessary to study the aggravating factors that change disease to impairments and impairments to handicaps in the elderly. ACKNOWLEDGMENTS This work was supported in part by the Rockefeller Foundation’s Inter- vention Research grant RF 97045 no. 90 to the author; supplemental sup- port was provided by the National Research Council of the National Acad- emy of Sciences of the United States and the PRONUSTIC Research Laboratory at the University of Montreal. I thank two anonymous referees for their suggestions and comments. REFERENCES Alter, G., Oris, M., Neven, M., and Broström, G. (2002). Maternal depletion and mortality after the childbearing years in the nineteenth century East Belgium. (Early Life Condi- tions, Social Mobility, and Longevity Working Paper Series 7). Presented at the Social Science History Association, October 24-27, St. Louis, MO. Anker, R., Buvinic, M., and Youssef, N.H. (Eds.). (1983). Women’s roles and population trends in the third world. London, England: Croom Helm. Arber, S., and Ginn, J. (1993). Gender and inequalities in health in later life. Social Science and Medicine, 36, 33-46. Bledsoe, C. (2002). Contingent lives: Fertility, time and aging in West Africa. (with contribu- tions by Fatoumatta Banja). Chicago, IL: University of Chicago Press. Bjorner, J.B., Kristensen, T.S., Orth-Gomer, K., Tibblin, G., Sullivan, M., and Westerholm, P. (1996). Self-rated health: A useful concept in research, prevention, and clinical medicine. Stockholm, Sweden: Forskningsrädsnämnden. Conde-Agudelo, A., and Belizan, J. (2000). Maternal morbidity and mortality associated with interpregnancy interval: Cross sectional study. British Medical Journal, 321, 1255-1259. Farmer, M.M., and Ferraro, K.F. (1997). Distress and perceived health: Mechanisms of health decline. Journal of Health and Social Behavior, 39, 298-311. Ferraro, K.F., Farmer, M.M., and Wybraniec, J.A. (1997). Health trajectories: Long-term dy- namics among black and white adults. Journal of Health and Social Behavior, 38, 38-54. Gijsbers van Wijk, C.M., van Vliet, K.P., Kolk, A.M., and Everaerd, W.T. (1991). Symptom sensitivity and sex differences in physical morbidity: A review of health surveys in the United States and the Netherlands. Women’s Health, 17, 91-124. Gorman, M. (2002). Global ageing: The nongovernmental organization role in the developing world. International Journal of Epidemiology, 31, 782-785. Hammel, E.A., and Gullickson, A. (2004). Kinship structures and survival: Maternal mortality on the Croatian-Bosnian border 1750-1898. Population Studies, 58(2), 145-159. Helweg-Larsen, M., Kjoller, M., and Thoning, H. (2003). Do age and social relations moder- ate the relationships between self-rated health and mortality among adult Danes? Social Science and Medicine, 57, 1237-1247. Idler, E.L. (1993). Age differences in self-assessments of health: Age changes, cohort differ- ences, or survivorship? Journal of Gerontology: Social Sciences, 48, S289-S300.

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