Perception of Unmet Basic Needs As a Predictor of Mortality
Perception of Unmet Basic Needs As a Predictor of Mortality
Objectives: We sought to determine whether, among older adults (>65 years), a perception that their basic needs are not being met increased mortality risk and whether this risk varied by race/ethnicity.
Methods: We used Cox proportional hazards modeling to estimate the effect of perceived inadequacy in having one's basic needs (adequacy of income, quality of housing, and neighborhood safety) met on 10-year mortality rates.
Results: After control for age, gender, race/ethnicity, marital status, education, income, and cognitive and functional status at baseline, perceived inadequacy in having one's basic needs met was shown to be a significant predictor of mortality (P <.0001), but no significant differences by race/ethnicity were observed.
Conclusions: Perceived inadequacy in having one's basic needs met predicted mortality during a 10-year follow-up among community-dwelling elderly persons.
In community-based studies of older adults, self-perceptions of well-being are strong predictors of mortality. Perceptions of poor health and inadequate social networks have been associated with increased mortality. For example, Idler and colleagues found that self-rated good health was associated with a significantly reduced risk of mortality for men (odds ratio=0.52, 95% confidence interval [CI]=0.36, 0.73) but not for women, using data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up. Schoenfeld and colleagues found a significantly increased risk of mortality among even the healthiest elderly members of the community who rated their health as poor. Blazer found that perception of inadequate social support was a stronger predictor of mortality among adults older than 65 years than the size of the social network and social interactions. Levy and colleagues found that older people with more positive perceptions of aging were found to live longer.
Perceptions across several domains have been found to predict health outcomes in the elderly. To date, perceived health and social support have been studied most frequently. Other perceptions, however, such as those pertaining to economic security and well-being, may also be important predictors of health. In this regard, one of the most consistent findings in epidemiological studies is the association between indexes of socioeconomic status (SES) and health outcomes. Moreover, substantial evidence exists that socioeconomic conditions are powerful explanatory variables for racial disparities in health.
Beyond health and social support, perhaps the most important basic needs of older adults are economic security, adequate housing, and a safe environment. SES, for example, is a strong predictor of mortality. This association may in part stem from the association between low SES and living in neighborhoods that have fewer resources and more crime than do affluent neighborhoods. In fact, causal relationships may exist between crime and the appearance and design of buildings and streets. In one study, for example, older people who reported insecure neighborhood environments had a greater risk of functional deterioration over 1 year compared with those who reported living in secure neighborhoods.
Local neighborhood resources are likely to be more relevant for people with lower income because high-income people have greater mobility, allowing them to travel farther to obtain needed services and healthful products and to participate in extended social support networks. Moreover, neighborhood crime has been found to affect the health of older adults. For example, more than 33000 emergency department visits are made each year by older adults for injuries caused by assault. A substantial proportion of such assaults are related to the SES of the individual and living in a low-income neighborhood. The mistreatment of elderly persons, in turn, is associated with reduced survival. The disparity in mortality between socioeconomic groups in the United States is widening; according to the National Morbidity Followback Study, persons of lower SES are increasingly at higher risk for death compared with persons of higher SES. Despite an overall decline in death rates in United States, this disparity in mortality by SES has increased among men and women (women having lower SES than men) as well as among Whites and African Americans (African Americans having lower SES than Whites). Given the very real risk to the health of older adults from lack of economic resources, there is reason to believe that a perception of economic hardship, beyond actual low income, places a burden on the elderly and contributes to the disparity in mortality.
We do not know the reasons for this disparity in mortality among socioeconomic groups in the United States, although investigators have suggested that perceptions of well-being -- perceptions formed when people compare themselves with others -- may be an important predictor of mortality. For example, Wilkinson noted that many socioeconomic determinants of health reveal their effects through psychosocial pathways. The association between SES and health could reflect a correlation between relative rather than absolute income and health indicators. For example, based on measures of self-perceived health status, individuals living in states with the greatest inequalities in incomes are more likely to report their health as fair or poor compared with individuals living in states with the smallest inequalities, even after personal characteristics and an individual's income were accounted for in the analyses. Researchers have demonstrated that life expectancy increases as distribution of income becomes more egalitarian, whereas life expectancy is relatively unrelated to average income.
In the United States, clear racial differences in economic well-being exist. People of minority racial/ethnic groups face a range of negative experiences compared with White Americans. These negative experiences include decreased opportunities for employment and education, higher rates of poverty, increased risk of physical ailments such as hypertension, and prejudice and discrimination. Racial discrimination has been documented across an array of domains, including housing and access to medical treatment. Such discriminatory events are stressful. As a result of these stressful and demoralizing experiences, people from ethnic or racial minority groups might be expected to be at increased risk for adverse health-related outcomes. It is probable that these chronic stressors have long-term effects on health.
Although African American health status is slowly improving, the rate of improvement since 1980 has in general been lower than that of Whites. Several community studies have documented that in the United States, African Americans have substantially more health problems than do Whites, regardless of age. For example, in a longitudinal study of the elderly, Peek and colleagues found that African Americans were more likely than Whites to report a decline in their health, regardless of the health measure used, and that racial differences in the decline of health appear to be a consequence of economic and educational discrepancies between the 2 groups.
We therefore sought to determine whether the perception of inadequately met basic needs (insufficient income, inadequate housing, and unsafe neighborhoods) among older adults was a significant predictor of mortality and whether this perception varied by race in a community sample of elderly persons, the Duke University Established Populations for Epidemiologic Studies of the Elderly (EPESE). Many variables are associated with mortality in older people, including older age, male gender, functional impairment, and cognitive impairment. Therefore, any association between perceived inadequacy in fulfillment of basic needs and mortality must be adjusted for these covariates. We hypothesized, using a proportional hazards model controlling for known causes of mortality in older adults, including actual income, that perceived inadequacy in fulfillment of basic needs would predict 10-year mortality among both White and African Americans. We also predicted that perceived inadequacy of fulfillment of basic needs in African Americans would be less predictive of mortality than that in Whites, because other factors, such as actual lower income, would buffer the impact of perceived inadequacy of fulfillment of basic needs.
Objectives: We sought to determine whether, among older adults (>65 years), a perception that their basic needs are not being met increased mortality risk and whether this risk varied by race/ethnicity.
Methods: We used Cox proportional hazards modeling to estimate the effect of perceived inadequacy in having one's basic needs (adequacy of income, quality of housing, and neighborhood safety) met on 10-year mortality rates.
Results: After control for age, gender, race/ethnicity, marital status, education, income, and cognitive and functional status at baseline, perceived inadequacy in having one's basic needs met was shown to be a significant predictor of mortality (P <.0001), but no significant differences by race/ethnicity were observed.
Conclusions: Perceived inadequacy in having one's basic needs met predicted mortality during a 10-year follow-up among community-dwelling elderly persons.
In community-based studies of older adults, self-perceptions of well-being are strong predictors of mortality. Perceptions of poor health and inadequate social networks have been associated with increased mortality. For example, Idler and colleagues found that self-rated good health was associated with a significantly reduced risk of mortality for men (odds ratio=0.52, 95% confidence interval [CI]=0.36, 0.73) but not for women, using data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up. Schoenfeld and colleagues found a significantly increased risk of mortality among even the healthiest elderly members of the community who rated their health as poor. Blazer found that perception of inadequate social support was a stronger predictor of mortality among adults older than 65 years than the size of the social network and social interactions. Levy and colleagues found that older people with more positive perceptions of aging were found to live longer.
Perceptions across several domains have been found to predict health outcomes in the elderly. To date, perceived health and social support have been studied most frequently. Other perceptions, however, such as those pertaining to economic security and well-being, may also be important predictors of health. In this regard, one of the most consistent findings in epidemiological studies is the association between indexes of socioeconomic status (SES) and health outcomes. Moreover, substantial evidence exists that socioeconomic conditions are powerful explanatory variables for racial disparities in health.
Beyond health and social support, perhaps the most important basic needs of older adults are economic security, adequate housing, and a safe environment. SES, for example, is a strong predictor of mortality. This association may in part stem from the association between low SES and living in neighborhoods that have fewer resources and more crime than do affluent neighborhoods. In fact, causal relationships may exist between crime and the appearance and design of buildings and streets. In one study, for example, older people who reported insecure neighborhood environments had a greater risk of functional deterioration over 1 year compared with those who reported living in secure neighborhoods.
Local neighborhood resources are likely to be more relevant for people with lower income because high-income people have greater mobility, allowing them to travel farther to obtain needed services and healthful products and to participate in extended social support networks. Moreover, neighborhood crime has been found to affect the health of older adults. For example, more than 33000 emergency department visits are made each year by older adults for injuries caused by assault. A substantial proportion of such assaults are related to the SES of the individual and living in a low-income neighborhood. The mistreatment of elderly persons, in turn, is associated with reduced survival. The disparity in mortality between socioeconomic groups in the United States is widening; according to the National Morbidity Followback Study, persons of lower SES are increasingly at higher risk for death compared with persons of higher SES. Despite an overall decline in death rates in United States, this disparity in mortality by SES has increased among men and women (women having lower SES than men) as well as among Whites and African Americans (African Americans having lower SES than Whites). Given the very real risk to the health of older adults from lack of economic resources, there is reason to believe that a perception of economic hardship, beyond actual low income, places a burden on the elderly and contributes to the disparity in mortality.
We do not know the reasons for this disparity in mortality among socioeconomic groups in the United States, although investigators have suggested that perceptions of well-being -- perceptions formed when people compare themselves with others -- may be an important predictor of mortality. For example, Wilkinson noted that many socioeconomic determinants of health reveal their effects through psychosocial pathways. The association between SES and health could reflect a correlation between relative rather than absolute income and health indicators. For example, based on measures of self-perceived health status, individuals living in states with the greatest inequalities in incomes are more likely to report their health as fair or poor compared with individuals living in states with the smallest inequalities, even after personal characteristics and an individual's income were accounted for in the analyses. Researchers have demonstrated that life expectancy increases as distribution of income becomes more egalitarian, whereas life expectancy is relatively unrelated to average income.
In the United States, clear racial differences in economic well-being exist. People of minority racial/ethnic groups face a range of negative experiences compared with White Americans. These negative experiences include decreased opportunities for employment and education, higher rates of poverty, increased risk of physical ailments such as hypertension, and prejudice and discrimination. Racial discrimination has been documented across an array of domains, including housing and access to medical treatment. Such discriminatory events are stressful. As a result of these stressful and demoralizing experiences, people from ethnic or racial minority groups might be expected to be at increased risk for adverse health-related outcomes. It is probable that these chronic stressors have long-term effects on health.
Although African American health status is slowly improving, the rate of improvement since 1980 has in general been lower than that of Whites. Several community studies have documented that in the United States, African Americans have substantially more health problems than do Whites, regardless of age. For example, in a longitudinal study of the elderly, Peek and colleagues found that African Americans were more likely than Whites to report a decline in their health, regardless of the health measure used, and that racial differences in the decline of health appear to be a consequence of economic and educational discrepancies between the 2 groups.
We therefore sought to determine whether the perception of inadequately met basic needs (insufficient income, inadequate housing, and unsafe neighborhoods) among older adults was a significant predictor of mortality and whether this perception varied by race in a community sample of elderly persons, the Duke University Established Populations for Epidemiologic Studies of the Elderly (EPESE). Many variables are associated with mortality in older people, including older age, male gender, functional impairment, and cognitive impairment. Therefore, any association between perceived inadequacy in fulfillment of basic needs and mortality must be adjusted for these covariates. We hypothesized, using a proportional hazards model controlling for known causes of mortality in older adults, including actual income, that perceived inadequacy in fulfillment of basic needs would predict 10-year mortality among both White and African Americans. We also predicted that perceived inadequacy of fulfillment of basic needs in African Americans would be less predictive of mortality than that in Whites, because other factors, such as actual lower income, would buffer the impact of perceived inadequacy of fulfillment of basic needs.