Sex differences in vision and hearing impairments across age and European regions

doi:10.21203/rs.3.rs-1891526/v1

Aims

Although sensory impairments are common conditions among the elderly, research often fails to consider the role of sex. We examine sex differences in vision impairment (VI) and hearing impairment (HI) across age and European regions.

Methods

A cross-sectional study based on a pooled sample of 120,537 Europeans aged 50 + participating in the Survey of Health, Ageing and Retirement in Europe. Logistic regression models were used to examine associations.

Results

Generally, women reported more VI than men. This was the case for both close vision (OR 1.07, 95% CI 1.03; 1.11) and distant vision (OR 1.49, 95% CI 1.41; 1.57). Contrarily, women reported less HI than men (OR 0.71, 95% CI 0.68; 0.74). However, sex differences varied by age and regions. Sex differences in VI increased with advancing age, whereas the sex gap in HI decreased. For close vision, a female disadvantage was found from age 65 in Western, Southern and Eastern Europe and from age 80 + in Northern Europe. For distant vision, the female disadvantage was more pronounced and persisted in almost all age groups in the four regions. The female advantage in HI was found in all regions except for ages 80 + in Northern and Southern Europe. For dual sensory impairment (i.e., impaired vision and hearing), no overall sex difference was found, but a female advantage was demonstrated at ages 50–64 in all regions except Southern Europe.

Conclusions

Our findings demonstrate an overall consistent pattern across Europe with a female disadvantage in vision but an advantage in hearing.

Epidemiology

Gender Studies

Sex differencesL

vision impairment

hearing impairment

dual sensory impairment

Europe

SHARE

Sensory impairments such as vision impairment (VI) and hearing impairment (HI) are common conditions among the middle-aged and older population, and the prevalence of VI and HI increases with age ^1–3. VI and HI are some of the largest contributors to the global disease burden for older adults, resulting in a significant economic burden ⁴. Both VI and HI have been associated with several adverse effects such as low quality of life ¹, depression ⁵, falls ², lower cognitive function ⁶, and even increased risk of mortality ^{7, 8}. Co-occurring vision and hearing impairment is called dual sensory impairment (DSI) ⁵. Evidence suggests that the burden of DSI may surpass the combined effects of VI and HI alone leading to more detrimental outcomes in the elderly ⁹.

Sex differences in VI and HI have previously been reported. In general, women are at a higher risk of developing VI including serious eye diseases such as age-related macular degeneration, thyroid eye disease, cataract, or chronic dry eye disease ^{10, 11}. The higher life expectancy among women than among men has been suggested to be part of the explanation for the sex difference in VI ¹⁰. In contrast, age-related hearing loss (ARHL) is more common, more severe and has an earlier onset in men ¹². It is suggested that the sex difference in HI may be attributed to the distinct sex hormones of men and women, with oestrogen being the most important hormone ¹³. Differences in noise exposure between men and women have also been proposed as a main factor underlying sex differences, but even in the absence of noise exposure, sex differences in susceptibility to ARHL remain ¹². Generally, sex differences vary across health measures, age, time, and geographical regions ^14–17, which may also be the case regarding vision and hearing.

Aims

In this study, we aim to examine how sensory impairments vary across sex, age, and European regions, and to investigate sex differences in sensory impairments across age groups and regions among the middle-aged and older European population. The present study will shed light on sensory impairments (i.e., both close VI, distant VI, HI and DSI) even at very old ages, where data are sparse, and will produce some of the most detailed investigations to date about age-related and cross-national sex differences in vision and hearing impairments.

Setting and study population

SHARE is a multinational database containing data on various measures, such as health, socioeconomic factors, and social relations spanning across several countries among Europeans aged 50 years and older ¹⁸. Since 2004, biennial survey waves have been conducted, and the database now contains data from eight waves, with the latest being conducted in 2020. Today, SHARE is representing 28 European countries and Israel ¹⁹. SHARE is a longitudinal survey which, when possible, includes the same people in each wave, but to compensate for attrition and to maintain the younger age cohorts, refreshment samples are also drawn regularly ²⁰. SHARE data is collected according to strict quality standards and with ex-ante harmonised interviews¹⁸.

This study is based on a pooled cross-sectional sample of women and men aged 50 years and above from the 28 European countries participating in SHARE waves 1 (2004-05) to 8 (2019-20). We excluded waves 3 and 7 because they focused on retrospective life histories. Because no sex-by-wave interactions were found for vision and hearing (i.e., differences between men and women did not differ by waves), we pooled all SHARE waves. For DSI, a sex-by-wave interaction was found in the overall model (p = 0.032), but sex-by-wave interactions for the specific waves were insignificant. Pooling of all SHARE waves gave us a larger sample size and thus more strength to detect sex differences, particularly among the oldest people, for whom data are sparse. We excluded participants with missing data on age (n = 10), with missing values on both close vision, distant vision, and hearing (n = 544) and with missing cross-sectional probability weights (n = 536), ending up with a study population of 120,537 individuals corresponding to 288,352 observations. The number of participants by country and wave are shown in Supplementary Table 1.

Vision and hearing

Close vision was assessed by asking the participants: "How good is your eyesight for seeing things up close, like reading ordinary newspaper print (using glasses or contact lenses as usual)?" and distant vision was evaluated by the question: "How good is your eyesight for seeing things at a distance, like recognising a friend across the street (using glasses or contact lenses as usual)?". Hearing was measured by asking the participants: “Is your hearing [using a hearing aid as usual]”“excellent”, “very good”, “good”, “fair”, or “poor”. We dichotomised vision and hearing as good if participants reported “excellent”, “very good”, or “good” and as impaired if participants reported “fair” or “poor”. Participants with both impaired vision (i.e., impairment in either close and/or distant vision) and hearing were classified as having DSI.

Socio-demographic variables

Socio-demographic variables included sex, age at interview, wave, European region, comorbidities, self-rated health, marital status, educational level, and wealth. Age was grouped into three categories: 50–64 years, 65–79 years, and 80 + years. In line with recent SHARE studies ^{16, 21}, we grouped the 28 participating countries into four European regions: Northern Europe (Denmark, Sweden, Finland), Western Europe (Austria, Germany, the Netherlands, France, Switzerland, Belgium, Ireland, and Luxembourg), Southern Europe (Spain, Italy, Greece, Portugal, Cyprus, and Malta), and Eastern Europe (Czech Republic, Poland, Hungary, Slovenia, Estonia, Croatia, Lithuania, Bulgaria, Latvia, Romania, and Slovakia). Information about the included comorbidities was reported in response to the question: “Has a doctor ever told you that you had/do currently have one of the following conditions?” (Hypertension, stroke, diabetes, Parkinson's disease, and arthritis including rheumatoid arthritis, osteoarthritis, or rheumatism). Self-rated health was assessed with a generic question and dichotomised into good (excellent, very good, or good) and poor (fair or poor). Marital status was grouped into three categories: Married/registered partnership, unmarried/divorced and widowed. Education was measured by the International Standard Classification of Education (ISCED) grouped into lower (ISCED 0–2), medium (ISCED 3–4) and higher (ISCED 5–6). Wealth was the sum of household net financial assets and household real assets and was based on the imputed imputations provided by SHARE. Demographic characteristics of the study population are given in Supplementary Table 2.

Statistical analyses

Logistic regression models providing odds ratios (ORs) and 95% confidence intervals (CIs) were used to investigate sex differences in close VI, distant VI, HI, and DSI. The main analysis was adjusted for age group, European region, and wave. Furthermore, we carried out separate analyses for each age group and region, because significant sex-by-age and sex-by-region interactions were found (Supplementary Table 3). To investigate the degree to which health and socioeconomic status could explain the differences between men and women, we performed a model further adjusted for comorbidities, self-rated health, marital status, education, and wealth. We performed a sensitivity analysis where we included only people at first intake (i.e., the first time they participated in one of the SHARE waves). To evaluate how much sensory aids influenced the results, we repeated the main analyses including people who used sensory aids (i.e., glasses/contact lenses or hearing aids) in the impaired categories independent of their answers to the questions posed.

In all models, we used robust standard errors from clustered analyses to account for repeated measurements from individuals participating in more than one wave of SHARE, and we applied the calibrated cross-sectional individual probability weights, available in the SHARE data. We adjusted for multiple testing by the Holm-Bonferroni correction in R version 3.6.1. All other analyses were conducted with Stata version 17.0.

A total of 65,656 (54.5%) women and 54,881 (45.5%) men were included in the study. The sample mean age was 64.8 years (standard deviation (SD) = 10.4) for women and 64.5 years (SD = 9.8) for men (Table 1). Overall, a total of 25.8% of women and 24.8% of men reported close VI, 17.4% of women and 12.5% of men reported distant VI, 16.0% of women and 21.4% of men reported HI, and 8.5% of women and 9.3% of men reported DSI (Table 1). The proportion of participants with VI, HI and DSI increased with advancing age and varied by European regions, with the highest proportions of sensory impairments in Southern and Eastern Europe (Fig. 1A-D).

Table 1

Characteristics of women and men aged 50 + participating in the Survey of Health, Ageing and Retirement in Europe (SHARE) between 2004-05 and 2020
	All countries		Northern Europe^a		Western Europe^b		Southern Europe^c		Eastern Europe^d
	Men	Women	Men	Women	Men	Women	Men	Women	Men	Women
Number of observations	127,716	160,636	16,560	19,145	52,304	63,967	27,795	33,905	31,057	43,619
N (%) individuals	54,881 (45.5)	65,656 (54.5)	6,220 (47.4)	6,914 (52.6)	20,877 (46.3)	24,250 (53.7)	12,118 (46.4)	13,974 (53.6)	15,666 (43.3)	20,518 (56.7)
Age groups
50–64 years	29,768 (54.2)	35,478 (54.0)	3,255 (52.3)	3,749 (54.2)	12,056 (57.8)	13,933 (57.5)	6,250 (51.6)	7,318 (52.4)	8,207 (52.4)	10,478 (51.1)
65–79 years	20,463 (37.3)	23,307 (35.5)	2,391 (38.4)	2,500 (36.2)	7,242 (34.7)	7,925 (32.7)	4,679 (38.6)	5,052 (36.2)	6,151 (39.3)	7,830 (38.2)
80 + years	4,650 (8.5)	6,871 (10.5)	574 (9.2)	665 (9.6)	1,579 (7.6)	2,392 (9.9)	1,189 (9.8)	1,604 (11.5)	1,308 (8.4)	2,210 (10.8)
Age in years, mean (SD)	64.5 (9.8)	64.8 (10.4)	64.8 (10.0)	64.5 (10.3)	63.7 (9.8)	64.0 (10.4)	65.2 (10.0)	65.2 (10.6)	65.0 (9.4)	65.5 (10.0)
Impairments
Close vision	13,571 (24.8)	16,921 (25.8)	919 (14.8)	938 (13.6)	4,177 (20.0)	4,849 (20.0)	3,431 (28.4)	4,373 (31.3)	5,044 (32.2)	6,761 (33.0)
Distant vision	6,866 (12.5)	11,382 (17.4)	386 (6.2)	631 (9.2)	1,661 (8.0)	2,839 (11.7)	2,122 (17.5)	3,231 (23.2)	2,697 (17.2)	4,681 (22.8)
Hearing	11,737 (21.4)	10,531 (16.0)	1,178 (18.9)	809 (11.7)	4,438 (21.3)	3,489 (14.4)	2,518 (20.8)	2,484 (17.8)	3,603 (23.0)	3,749 (18.3)
Dual sensory	5,106 (9.3)	5,566 (8.5)	319 (5.1)	264 (3.8)	1,445 (6.9)	1,380 (5.7)	1,313 (10.8)	1,522 (10.9)	2,029 (13.0)	2,400 (11.7)
Regular use of sensory aids
Glasses or contact lenses	36,451 (66.4)	47,234 (72.0)	5,090 (81.8)	6,057 (87.6)	14,461 (69.3)	18,090 (74.6)	8,000 (66.0)	10,064 (72.0)	8,900 (56.8)	13,023 (63.5)
Hearing aids	2,980 (5.9)	2,564 (4.3)	684 (12.0)	481 (7.6)	1,393 (6.7)	1,184 (4.9)	371 (3.2)	359 (2.7)	532 (4.1)	540 (3.3)
Data are N (%) unless otherwise stated.
SD = standard deviation.
Missing: 0% for hearing and glasses, 0.1% for vision close and dual sensory impairment, 0.2% for vision distant, and 7.8% (7.3% for men and 8.3% for women) for hearing aid. Missing values are excluded from percentage calculations.
^aSweden, Denmark, and Finland.
^bAustria, Germany, the Netherlands, France, Switzerland, Belgium, Ireland, and Luxembourg.
^cSpain, Italy, Greece, Portugal, Cyprus, and Malta.
^dCzech Republic, Poland, Hungary, Slovenia, Estonia, Croatia, Lithuania, Bulgaria, Latvia, Romania, and Slovakia.

[Table 1 and Fig. 1 about here]

Overall, women reported higher odds of VI than men regarding both close vision (OR 1.07, 95% CI 1.03; 1.11) and distant vision (OR 1.49, 95% CI 1.41; 1.57). For close and distant vision, sex-by-age interactions were found, i.e., sex differences increased with advancing age (Fig. 2A-B). For close vision, sex differences varied by European regions. A female advantage was found at ages 50–64 years in Northern and Eastern Europe, whereas a female disadvantage was found from age 65 in Western, Southern and Eastern Europe and from age 80 + years in Northern Europe (Fig. 2A, Supplementary Table 4). For distant vision, no sex-by-region interaction was found. The female disadvantage was more pronounced than for close vision and persisted across all age groups in the four European regions except from ages 50–64 years in Northern Europe (Fig. 2B, Supplementary Table 5). When combining close and distant vision in the main model, we found an overall female disadvantage in all regions except from Northern Europe. Only in Southern Europe a sex difference was found in the youngest age groups, but from age 65 years and above a female disadvantage was present in all European regions (Supplementary Table 6).

Regarding hearing, lower odds of impairment was found for women than for men with an overall OR of 0.71 (95% CI 0.68; 0.74). A significant sex-by-age interaction was found with sex differences decreasing with advancing age. Regional differences were also present, but the male disadvantage persisted in all age groups in the four European regions except from ages 80 + years in Northern and Southern Europe. Overall, the largest female advantage was found in Northern Europe (OR = 0.59, 95% CI 0.54; 0.65) and the smallest in Southern Europe (OR = 0.79, 95% CI 0.72; 0.86) (Fig. 2C, Supplementary Table 7).

No overall sex difference was found for DSI (OR = 0.96, 95% CI 0.90; 1.02), but lower odds for women than for men was found at ages 50–64 years (OR = 0.76, 95% CI 0.67; 0.87). Lower odds of DSI for women were found in the youngest age group in all regions except Southern Europe, where no sex differences were found. In Northern Europe, the female advantage persisted until age 79 years (Fig. 2D, Supplementary Table 8).

When we further adjusted the analyses for health and socioeconomic status, the results were overall slightly changed towards a female advantage, and no sex differences were found for close vision. When we repeated the analyses including only people at first intake, the patterns were consistent with the main model (Supplementary Tables 4–5,7–8). When adding people wearing sensory aids to the impaired categories, we found sex differences in vision impairment to be increased and significant in all age groups in the four European regions except in the oldest age groups in Northern and Eastern Europe. When we included people using sensory aids to the impaired category for hearing and dual sensory impairments, results were generally consistent with the main results (Supplementary Tables 6–8). After adjustment for multiple testing, all overall results remained significant (Supplementary Tables 4–8).

[Figure 2 about here]

In this large cross-national study, we found that women have more VI but less HI than men; however, the pattern of sex differences varied across age groups and European regions. Sex differences in VI increased with advancing age, whereas the sex gap in HI decreased. A North-South gradient was indicated showing the largest sex difference in close VI in Southern Europe and the smallest sex gaps in close VI, HI and DSI in Northern Europe. Overall, sensory impairments varied between European regions, with the highest proportion of impairments in Southern and Eastern Europe and the lowest in Northern Europe. This pattern might to some extent be explained by regional differences in the use of sensory aids.

In line with previous evidence ^{2, 22}, slightly more than one third of Europeans aged 50 + years reported difficulties in either vision or hearing. In general, we found the lowest prevalences of sensory impairments in Northern and Western Europe, which could be due to more use of sensory aids in these regions. In this study, Northern Europe including Denmark, Sweden and Finland had the highest proportion of people reporting regular use of glasses/contact lenses and hearing aids. Studies from Europe and the US have reported an underuse of hearing aids ^{2, 3}. In accordance with these findings, our study indicates an underuse of hearing aids in all European regions, but with the greatest underuse in Southern and Eastern Europe.

The present findings that sex differences in VI increase with advancing age and that sex differences in HI decrease, point towards an increased disadvantage for women with advancing age in line with several other health outcomes such as quality of life ¹⁶, functional limitations ¹⁷, cognitive function ¹⁵, comorbidity and frailty ¹⁴. This is consistent with a survival effect, where only the healthiest men survive to older ages ²³. Consistent with previous cross-national evidence on other health-related outcomes ^14–17, we found a North-South gradient with the largest female disadvantage in close VI in Southern Europe, and the largest female advantage in close VI, HI and DSI in Northern Europe. This is in line with earlier evidence suggesting that the greater gender equality in the Nordic countries has a positive effect mainly on the health of women ^{24, 25}. However, contrary to expected, we found no regional differences in distant VI, which showed a consistent female disadvantage across Europe. This highlights the need for differentiating between close and distant eyesight in future studies.

The higher prevalence of VI in women than in men has previously been noted particularly in low and middle-income countries, and factors contributing to this disparity are complex ²⁶. It can be attributed to biological factors including the increased longevity in women, but also the greater susceptibility to conditions that lead to VI such as the higher prevalence of cataract among women ^{26, 27}. The sex difference in hearing may be attributed to the distinct sex hormones in men and women, with oestrogen protecting premenopausal women from the onset of a declining auditory system; but other factors than hormones, such as noise exposures, are also suggested ^{12, 13}. According to Homans et al., men have better hearing thresholds now than previously, particularly in the younger age groups. This may be explained by more frequent use of occupational noise protection due to growing public awareness and stricter regulations. Contrarily, women have worse hearing thresholds compared to older cohorts, which could be explained by women having a lifestyle that is more similar to men compared with previous times, suggesting that environmental and lifestyle factors influence the development of ARHL ²⁸.

Our findings support the importance of social explanations for sex differences in VI and HI. However, the sex gap in distant vision decreased by only 13%, and the sex gap in HI increased by 16% after adjustment for health and socioeconomic status, suggesting that these explanations are not the main reasons for the sex differences. In this study, no sex-by-wave interactions were found, indicating that sex differences did not change over the study period ranging between 2004-05 and 2020.

Although many causes of VI are preventable or treatable, eye health is often not prioritized in research and public health policy ¹⁰. Particularly, research often fails to consider the role of sex in eye health, leaving gaps in the ability to address differences in patient populations and outcomes ¹⁰. Also, regarding research within ARHL, basic and preclinical research studies have largely ignored the impact of sex as a biological variable ¹². Through an understanding of the role of sex in the etiology of complex diseases like ARHL, the ability to understand and manipulate the underlying molecular pathways driving the disease will increase ¹².

The largest strength of this study is the very large sample size including 288,352 observations with a low proportion of missing data, providing great power to detect sex differences in sensory impairments across age and European regions. Moreover, we distinguish between close and distant VI. A potential concern is that this study is based on self-reported vision and hearing impairments. Self-reporting is always associated with some uncertainty, but self-reported assessment of sensory impairment has previously been deemed an accurate measure of both VI and HI in the elderly ^{29, 30}. Nevertheless, in SHARE, questions about sensory impairments take the use of glasses and hearing aids into account. These questions provide information about perceived difficulties in vision and hearing in the everyday environment ²², but the proportion of impairments may be slightly underestimated compared with objective measures. This is expected to be most pronounced in Northern Europe, which had the highest proportions of people reporting the use of sensory aids. When we included all individuals using sensory aids in the impaired category, the results suggested that sex differences in VI had been more pronounced, particularly in Northern Europe, if eyesight was measured without considering aids.

To our knowledge, this is the first study to investigate sex differences in VI, HI and DSI across age and European regions. The findings confirm that women report more VI than men, particularly regarding distant vision, whereas women report less HI. However, with advancing age the female disadvantage in VI increased and the female advantage in hearing decreased. A North-South gradient with the largest female advantage in Northern Europe was indicated, but overall findings were consistent across Europe particularly regarding distant VI. Future studies should consider sex differences in the associations between sensory impairments and health, and preferably differentiate between close and distant eyesight, and health policies should focus on earlier detection and treatment of sensory impairments, with a particular focus on women’s eye health and men’s hearing.

Acknowledgements

This paper uses data from SHARE Waves 1, 2, 4, 5, 6, and 8 (DOIs: 10.6103/SHARE.w1.800, 10.6103/SHARE.w2.800, 10.6103/SHARE.w4.800, 10.6103/SHARE.w5.800, 10.6103/SHARE.w6.800,10.6103/SHARE.w8.800), see Börsch-Supan et al. (2013) for methodological details ¹⁸. The SHARE data collection has been funded by the European Commission, DG RTD through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812), FP7 (SHARE-PREP: GA N°211909, SHARE-LEAP: GA N°227822, SHARE M4: GA N°261982, DASISH: GA N°283646) and Horizon 2020 (SHARE-DEV3: GA N°676536, SHARE-COHESION: GA N°870628, SERISS: GA N°654221, SSHOC: GA N°823782, SHARE-COVID19: GA N°101015924) and by DG Employment, Social Affairs & Inclusion through VS 2015/0195, VS 2016/0135, VS 2018/0285, VS 2019/0332, and VS 2020/0313. Additional funding from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, the U.S. National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, OGHA_04-064, HHSN271201300071C, RAG052527A) and from various national funding sources is gratefully acknowledged (see www.share-project.org).

Declaration of conflicting interests

The authors declare no potential conflicts of interests.

Funding

This research was funded by Demography of Sex Differences in Health and Survival, grant number P01 AG031719 (LJA)

Data availability

SHARE data is free of charge for scientific use globally http://www.share-project.org/data-access.html

Conflicts of interest

None declared

ORCID ID

Rikke Syrak Hansen: 0000-0002-2298-5993

Lasse Lybecker Scheel-Hincke: 0000-0002-4672-8959

Linda Juel Ahrenfeldt: 0000-0002-5018-1642

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SupplementaryTables.docx

Sex differences in vision and hearing impairments across age and European regions

Status:

Version 1

Abstract

Aims

Methods

Results

Conclusions

Figures

Background

Aims

Methods

Setting and study population

Vision and hearing

Socio-demographic variables

Statistical analyses

Results

Discussion

Conclusions

Declarations

References

Supplementary Files

Status:

Version 1