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Gender differences in living arrangements and chronic conditions and health

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DOI: 10.30126/JoS

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 Original Articles

Gender Differences in the Association Between Living Alone,

Chronic Disease and Health Service Use

Dennis Asante1*, Vivian Isaac1,2

Abstract: Objectives: To evaluate the associations between living alone, chronic physical and mental
health problems, health services use and how it varies across gender.Methods: A secondary analysis of the
nationally representative sample of older adults from the South Australian Monitoring and Surveillance
Survey (SAMSS) data (n= 20,522). Chi-square analysis was conducted to examine differences in
associations between living arrangements and prevalence of chronic health conditions; and living
arrangements and health service use. These analyses were stratified by gender.Results: Urban residence,
female gender, increasing age (80+), and lower educational attainment were significantly associated with
lonely living among older adults. Living alone was associated with higher burden of physical and mental
health conditions, marked by gender differences.While males who were living alone reported higher
prevalence of physical health conditions, their female counterparts had higher prevalence of depressive and
anxiety symptoms. However, suicide ideation was more common in males than females who were living
alone. Importantly, older people who were living alone significantly used higher health services than those
who lived with others.Conclusion: Living alone is a risk marker for physical and mental health conditions,
particularly suicide ideation. There were gender differences in the association between living alone, chronic
health conditions and healthcare demand among older people.

Keywords: living alone, older adults, physical and mental conditions.

( Journal of Suicidology 2023; 18(1): 434-440. DOI:10.30126/JoS.202303_18(1).0003)

Introduction A recent study on living alone and suicide risk in

Living alone has become very common in modern
societies [1, 2]. Available statistics indicate that about
33% of older adults were living alone in UK [3], 24.6%
in Canada, 22% in New Zealand, 40% in Germany [4],
and 28.5% in the U.S [5]. Currently, about 25% of older
adults (≥65 years) and 35% of those aged 85 or above
are living alone in Australia [6]. Evidence suggests
that living alone is associated with social isolation and
loneliness in older adults [7]. Moreover, living alone is
an independent risk factor for mortalities in late life [8, 9].
Living alone is a well-established risk factor for
poor mental health [10]. Dreger and colleagues [11]
reported that adults (18+) without partners nor children
living with them had poorer mental health and this
association remained significant after adjustment for
sociodemographic and psychological factors. Similarly,
De Moortel et al. [12] found older women living alone to
have higher risk of poor mental health than those living
their with relatives. Lukaschek et al. [13] reported similar
findings regarding older women living alone. They found
that living alone was associated with low subjective
wellbeing in women but not in men. Further, older
adults who live alone have higher levels of depressive
symptoms after adjusting for known confounders of
depression in old age [14, 15].
the United States has demonstrated higher rate of both
suicide attempts and suicide deaths in adults who live
alone (23%) than those living with other people (13.2%)
[16]. Another study found significant association between
living alone and suicide for men, but no association was
found for women. In the fully adjusted models, loneliness
was found to be associated with hospital admissions
for self-harm in both men and women [17]. Similar
association between living alone and suicide behaviours
has been reported by other researchers [18, 19].
There is a marked gender difference in the living
arrangements of Australian older adults where women
are more likely to live alone than men. This phenomenon
has been attributed to the fact that Australian women
generally live longer than men [20]. According to
a report by the Australian Bureau of Statistics [21],
approximately 1 in every 3 (31%) older women lives
alone compared with 1in 5 (18%) for older men. The
difference is even wider for the oldest old (≥85 years)
with 41% older women living in a lone person household
compared with 25% for men [21]. Despite the high
numbers of the older population living alone with a clear
gender difference, research directed towards physical
and mental wellbeing of older Australians related to
living alone has been limited. Joe et al. [20] assessed the
association between living alone and use of home nursing
service among older (55+) women in metropolitan

1 College of Medicine & Public Health, Rural and Remote Health, Flinders University, Renmark, SA, Australia; 2 School of Allied Health, Exercise
and Sports Sciences/ faculty of Sciences and Health, Charles Sturt University, Albury, NSW.
*
Correspondence to: Dennis Asante, Rural and Remote Health SA, Ral Ral Avenue, Flinders University, Renmark Campus, South Australia, 5341;
Phone: +61406200657; E-mail: dennis.asante@flinders.edu.au
Received: 15 February 2023; Accepted: 14 March 2023.

Journal of Suicidology 2023 Vol. 18 No. 1 434

Loneliness and Morbidities in Older Adults
Melbourne. Mu and colleagues [2] also examined living
alone and risk of hospitalization among individuals aged
45 and above using a sample of 5,247. Both studies
have reported significant associations between living
alone and service use. However, gender differences in
the associations between living alone, chronic physical
and mental problems and health service use is not well
understood.
Addressing these gaps, we contribute to the
literature by focusing our study on community-dwelling
older adults (≥60 years) across rural and urban South
Australia to assess the relationships between living alone,
chronic physical and mental health conditions and health
services use. Hence, we aimed to 1) understand gender
differences in the associations between living alone,
health status and health services use and 2) to compare
rural-urban difference in living arrangements of the older
population.
Method
Survey design and research sample
This study employed data from the South Australia's
Department of Health and Aging database, which
was collected between 2013 and 2017. The sample
of the survey constituted all eligible South Australia's
households that are found on the Electronic White Pages
[22]. In this context, eligible participants comprised all
age groups with access to a telephone [23]. In every
year, a total of 7,000 South Australians participate in
the survey. Overall, 69% of the participants participated
in the survey, which constitutes the response rate. The
survey uses a dual over-lapping sampling approach
(mobile phone 70%; landline 30%) via random digit
dialling [24]. The rationale was to capture a more
representative sample of the population.
Beyond tracking the patterns of disease conditions,
the survey also checks health care challenges and health
service-related issues at frequent periods which is integral
to South Australia [23]. The essence of the survey is
to remedy the health care needs of the population in
South Australia by formulating more responsive and
tailored health policies and/or programmes [22]. Aside
from the above, the survey seeks to check both state and
national health priority areas to measure the effectiveness
of health policy interventions [23]. Also, the survey
provides adequate and needed retrospective population
health information for monitoring status, addressing
changes in the population as well as helping in the
formulation, implementation, and assessment of health
programmes.
Aided with Computer Assisted Telephone Interview
(CATI) technology, the survey was carried out by
professionals’ interviewers in English and lasted between
15 to 20 min. The CATI system facilitates immediate
data entry onto the computerized database from the
interviewer’ questionnaire. The use of CATI was due
to its highly ranked nature of having the capacity to
gather high quality data on rural and urban areas where
the expenditure of conducting face to face interviews
in earlier surveys has resulted in underrepresentation
[25]. A detailed information regarding the objectives,
methodology and initial reports of the survey has been
reported elsewhere [22].
Journal of Suicidology 2023 Vol. 18 No. 1 435
Dennis Asante, Vivian Isaac
We adopted the Modified Monash Model (MMM)
of geographical taxonomy to differentiate between urban,
rural, and remote areas. The classification of the study
area into urban, rural and remotes was to enable us to
examine the differences in living alone, chronic health
conditions, self-rated health, and health service utilization
by place of residence (geography). On a scale of MM1
to MM7, the model helped us to determine remoteness
and population size [26]. Based on population size and
remoteness from the cities and services, we denoted
urban, rural, and remote as MM1, MM2-4 and MM5-7
which is consistent with existing literature [27].
Ethics approval
The study received approval from the South
Australia Department for Health and Wellbeing Human
Research Ethics Committee: HREC/18/SAH/89
Variable measures
The use of formal healthcare services (general
practice (GP), hospital admission, and emergency
department (ED) visits) were the dependent variables. GP
service use was initially measured through a continuous
scale where older adults reported actual number of times
of accessing GP services during the last 4 weeks prior
to the survey. To distinguish between low and higher
use of this service, we recoded the responses into three
categories: no GP use= no, low GP use= 1-5 visits, and
high GP use= ≥6 visits. Of note, this way of classifying
GP utilisation was based on the objective of the study,
response frequencies, and consideration of similar
studies in literature [24, 28]. Both hospital admission and
ED were assessed dichotomously (1= yes / 2= no). Older
adults reported whether they have ever-used hospital
admission and ED services in the past four weeks.
The independent variables were chronic physical
health conditions and common mental health conditions
and living arrangement. Older people were made to
indicate using “yes” or “no” any doctor diagnosed
chronic health condition(s) through survey items “Have
you been told by a doctor that you have had ….?”
Common physical health conditions reported included
Cancer, diabetes, heart disease, stroke, and asthma.
Mental health conditions included anxiety, depression,
and suicide ideation. Older adults were considered to
live alone if their housing is such that nobody lives with
them. Other categorical variables included education
(primary, high school, and diploma or above), gender,
age (60-69, 70-79, and ≥80), and geographical location
(urban, rural, and remote). These characteristics of the
sample are depicted in Table1.
Data analysis
Survey data on older adults (≥60 years); total sample
of 20,522 were analysed using univariate descriptive
statistics to generate distributional characteristics. The
data was analysed based on gender and geographical
location. Chi-square analysis was conducted to examine
differences in associations between living arrangements
and prevalence of chronic health conditions, living
arrangements and health service use by gender. The
Statistical Package for Social Sciences (SPSS) software
version 24.0 (IBM Corp., Armonk, New York, USA)
Loneliness and Morbidities in Older Adults
aided all the statistical analysis performed. Statistical
significance was defined at a p-value of 0.05 or less.
Results
A total of 20,522 observations were analysed,
comprising urban (n = 13,498), rural (n = 2,981) and
remote locations (n = 4,043). In the population sample,
60.7% were women and the majority 8,889 (43.3%) of
the respondents were within the 60–69 age bracket. More
older people in urban were living alone than in rural
and remote areas. Specifically, while 40.5% of older
individuals in urban areas were living alone compared
to 59.5% living with relatives, the proportions for rural
were 37.2% (living alone) versus 62.8% (not living
alone) and remote 35.4% (living alone) versus 64.6% (not
living alone). Females (45.9%) were more likely to live
alone than men (28.8%). Living alone was associated
with increasing age and lower educational attainment
(Table 1).
Living alone, gender, and health conditions
Chronic health conditions were more prevalent in
older adults who were living alone compared to those
who lived with other people. About 17% of older adults
who were living alone had doctor diagnosed diabetes
compared to 15% for those living with others. There
were similar significant higher proportions for those
living alone with heart disease 10.2%, stroke 4.9%,
depression 7.2%, and among others (Table 2). Gender
demonstrated significant difference in the relationship
between living alone and prevalence of reported doctor
diagnosed conditions. Overall, higher proportions of
solely living older males had doctor diagnosed physical
health condition(s) than their female counterparts. For
instance, while 28.1% of males who live alone had
cancer, the percentage for their female counterpart was
23.3%. However, mental health conditions were more
common in females than in males. Higher burden of
depression and anxiety was observed in older females
Table 1. Sample characteristics (living status and sociodemographic characteristics).
Sociodemographic Alone
N (%)
Education
Basic 916 (57.6)
High school 4270 (41.2)
Diploma+ 2827 (33.1)
Age
60-69 2360 (26.5)
70-79 2838 (39.2)
80+ 2830 (64.3)
Gender
Male 2310 (28.8)
Female 5718 (45.9)
Geographical location
Urban 5708 (40.5)
Rural 890 (37.2)
Remote 1430 (35.4)
Journal of Suicidology 2023 Vol. 18 No. 1 436
Dennis Asante, Vivian Isaac
living alone than their male counterparts. Significantly
more males who were living alone reported suicide
ideation than females (Table 2).
Living alone and health services use
Living alone was associated with higher demand
for healthcare services. Females were significantly more
likely to frequently use healthcare services than males.
Specifically, while 44% of male living alone reported
significantly higher percentage of high GP visits (≥6
visits within a year) than those living with others (36%),
the proportions for females were 46.3% (living alone)
and 36.8% (not living alone). ED and hospital admissions
followed a similar pattern as shown in Table 3.
Discussion
This study analysed data on 20,522 older adults
across rural and urban South Australia to explore the
associations between living alone, chronic health
conditions, and health services use. Gender differences
in these associations was examined. Overall, more older
adults in urban areas tended to live alone than those in
rural and remote areas. Significant associations were
found between living alone, female gender, increasing
age, and lower education across the study areas. Living
alone was associated with higher physical and mental
health problems including suicide ideation with male
gender bearing the greatest proportions of physical health
conditions. Moreover, living alone was associated with
higher health services use and that females who were
living alone accessed services at higher levels than their
male counterparts.
Urban residence, female gender, increasing age,
and lower education were associated with living alone in
late life. Our results are consistent with previous studies
[29-31]. In Australia, the relationship between living
alone and education has been found to differ between
men and women [4]. The educational level of women
who lived alone was quite different to that of men who
Not alone χ2 p-value
N (%)
675 (42.4) 375.228 < .001
6086 (58.8)
5705 (66.9)
6529 (73.5) 1762.867 < .001
4395 (60.8)
1570 (35.7)
5763 (71.2) 616.667 < .001
6731 (54.1)
8379 (59.5) 39.137 < .001
1502 (62.8)
2613 (64.6)
Loneliness and Morbidities in Older Adults Dennis Asante, Vivian Isaac

Table 2. Living arrangement and physical health condition.

Condition Living N (%) Male χ2 p-value Female χ2 p-value
status N (%) N (%)
Physical health conditions

Cancer

Alone 1981 (24.7) 649 (28.1) 2.275 = .321 1332 (23.3) 12.513 < .002
Not alone 2928 (23.5) 1525 (26.5) 1403 (20.8)
Diabetes

Alone 1392 (17.4) 519 (22.5) 17.469 < .001 873 (15.3) 16.545 < .001
Not alone 1933 (15.5) 1073 (18.6) 860 (12.8)
Stroke

Alone 392 (4.9) 135 (5.8) 9.788 < .002 257 (4.5) 24.467 < .001
Not alone 434 (3.5) 243 (4.2) 191 (2.8)
Heart disease

Alone 820 (10.2) 289 (12.5) 2.652 = .103 531 (9.3) 41.993 < .001
Not alone 1064 (8.5) 647 (11.2) 417 (6.2)
Heart attack

Alone 578 (7.2) 288 (12.5) 13.451 < .001 290 (5.1) 37.245 < .001
Not alone 757 (6.1) 559 (9.7) 198 (2.9)
Asthma

Alone 1335 (16.6) 294 (12.7) 3.822 = .148 1041 (18.2) 1.817 = .403
Not alone 1936 (15.5) 758 (13.2) 1178 (17.5)
Emphysema/ chronic bronchitis

Alone 588 (7.3) 185 (8.0) 17.205 < .001 403 (7.0) 10.607 < .005
Not alone 712 (5.7) 323 (5.6) 389 (5.8)
Arthritis Osteoarthritis

Alone 3017 (37.6) 554 (24.0) 1.988 = .159 2463 (43.1) 23.497 < .001
Not alone 3909 (31.3) 1298 (22.5) 2611 (38.8)
Osteoporosis

Alone 1357 (16.9) 125 (5.4) 8.664 = .013 1232 (21.5) 65.549 < .001
Not alone 1390 (11.1) 265 (4.6) 1125 (16.7)

Metal health condition

Anxiety

Alone 454 (5.7) 99 (4.3) 7.847 < .005 355 (6.5) 3.368 = .066
Not alone 541 (4.3) 175 (3.0) 366 (5.4)
Depression

Alone 575 (7.2) 150 (6.5) 23.403 < .001 425 (7.4) 12.295 < .001
Not alone 624 (5.0) 229 (4.0) 395 (5.9)
Suicide ideation

Alone 100 (1.3) 39 (1.8) 22.776 < .001 61 (1.1%) 5.460 = .019
Not alone 80 (0.7) 34 (0.6) 46 (0.7)

Journal of Suicidology 2023 Vol. 18 No. 1 437

Loneliness and Morbidities in Older Adults
Table 3. Living alone and health services use.
Health Living Categories Male
service status N (%)
GP visit
Alone No 112 (4.9)
Low 1157 (51.1)
High 997 (44.0)
Not alone No 197 (3.5)
Low 3451 (60.5)
High 2055 (36.0)
Hospital admission
Alone Ever-visit 101 (4.4)
Not alone 170 (2.9)
ED visits
Alone Ever-visit 75 (3.2)
Not alone 130 (2.3)
Note: GP = general practice; ED = emergency department.
lived alone. Women who lived alone stood out for having
high levels of education while men who lived alone had
relatively low education [4]. The author further reported
that high education of women who were living alone
was especially evident for women aged under 60 and
clearest among those aged under 40. These women who
were living alone had higher education than women who
were not living alone and higher education than men in
general [4].
Increasing age (80 years or above) and female
gender elevated the risk of living alone in this study.
Advancement in age adversely affects physical abilities
and health status, which may increase the need for
assistance with daily living activities [32]. This finding
suggests that many older people, particularly the oldest
old who may need assistance with daily activities are
missing out with the needed support. Wandera and
colleagues [33] have demonstrated that higher risk of
chronic non-communicable ailments with negative health
outcomes were more prevalent among the oldest old.
According to the Australian Bureau of Statistics [34],
different life expectancies for males and females can be
attributed to the greater numbers of older women living
alone than their men counterparts. In Australia, men aged
65 in 2018–2020 could expect to live another 20.3 years
(an expected age at death of 85.3 years), and women
aged 65 in 2018–2020 could expect to live another
23.0 years (an expected age at death of 88.0 years [35].
A study conducted in the US showed that more older
women were likely to live alone than older men [36].
We also found that living alone was associated
with higher physical and mental health problems.
This corroborates earlier reports [10, 37] where living
alone has been found to predict poor health in older
populations. However, there were statistically significant
gender differences in all the health conditions examined.
Among those living alone, mental health conditions
(depression and anxiety) were higher in women than
men. However, men who were living alone reported
higher rate of suicide ideation. Men reported higher
burden of the physical health conditions than their
women counterparts. This is consistent with Hana Ko et
Journal of Suicidology 2023 Vol. 18 No. 1 438
Dennis Asante, Vivian Isaac
χ2 p-value Female χ2 p-value
N (%)
61.184 < .001 137 (2.5) 113.540 < .001
2845 (51.3)
2567 (46.3)
215 (3.2)
3970 (60.0)
2433 (36.8)
10.285 < .001 208 (3.6) 4.747 < .029
198 (2.9)
6.544 = .011 182 (3.2) 13.203 < .001
144 (2.1)
al [38] study in which men were found to be more likely
than women to report poor health conditions including
suicide ideation. Many other local and international
studies have reported similar associations between living
alone and poor physical and mental health [2, 8, 12].
For instance, Olfson et al [16] recently demonstrated
that living alone is a risk factor for suicide behaviours in
older adults.
Finally, as anticipated [2, 39], living alone was
strongly associated with increased health services
(GP visits, Hospitalization, and ED visits) use. The
relationship between living alone and health services
use was largely similar in both genders. However, more
females (46.3%) than males (44.0%) self-reported high
GP visits (6 or more visits in a year) prior to the survey.
These findings are consistent with those presented in
most comparable Australian and international studies.
In Australia, Mu, Kecmanovic and Hall [2] found that
patients who lived alone have a 2.7% higher likelihood
of accessing inpatient services. A similar study in
London have reported a stronger association between
older people living alone and ED visits [39]. Despite
the structural differences of health care systems across
countries, the findings in this study are consistent with
existing literature from different cultures and provide
additional evidence that older adults living alone
are higher users of health services. Further, to our
knowledge, our study is the first in Australia to examine
gender difference in the association between living alone,
chronic burden and health services use, providing vital
information for policy and practice.
Limitation
Some limitations should be considered when
interpreting the results of this study. First, the findings
reflect a representative sample of the SAMSS survey data
and may not be reflective or generalisable to other States
in Australia. We analysed a secondary cross-sectional
data and hence, only associations without causality
should be inferred. Moreover, other crucial determinants
of health services utilization such as income levels and
Loneliness and Morbidities in Older Adults
socio-cultural factors [40-42] were not accounted for in
the current analysis. More in-depth analysis is warranted
to untangle the relationship between living alone,
chronic health conditions, suicide ideation, and health
care service use. Future studies may account for these
possible limitations and replicate our findings.
Conclusion
Older adults living alone experience higher burden
of physical and mental health conditions and are at
higher risk of suicide ideation. Clinicians working with
community-dwelling older people living alone should
anticipate higher levels of disease and disability in these
individuals, and higher health and suicide risk, much
of which will be due to older age, and male sex. Living
alone itself appears to be associated with higher need for
health services. Targeted population screening using lone
status may be useful in identifying older individuals at
high risk of chronicity and suicide ideation.
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