This study aimed to determine the prevalence of functional disabilities among Hispanics 65 years and older and to compare the prevalence of functional disabilities in specific self-care activities, IADLs and functional mobility between males and females; controlling for age, income, chronic conditions, and marital status. Two important findings were revealed in this study’s in-depth analysis. First, 58% of the Hispanic sample of older adults living in eight low-income communities in PR, had some type of physical function disability, with a higher prevalence among older females. Second, older female had each of the three disability types in a significant higher crude prevalence ratio (p < 0.05) than older males, that increased when adjusted for the sociodemographic variables.
The overall prevalence of physical function disability reported in the sample of this study (58%) is higher when compared to national and local data of representative samples with Hispanic populations. For example, data from the 2018 American Community Survey reported a disability prevalence 17.6% of independent living disability among Hispanic adults ≥ 65 years living in the USA and 26.6% among those Hispanic ≥ 65 years living in Puerto Rico . The high burden of functional disabilities in our sample can be explained by their sociodemographic characteristics that have explained increased risk in disability in other studies such as low economic status [31–33], low educational levels [34–36], and high prevalence of having multiple chronic conditions [37, 38]. Direct comparison of our findings with previous studies should be undertaken with caution, as different measurement criteria, data collection methods, study populations and geographical parameters can greatly affect outcomes.
Female sex was associated with higher functional disability prevalence, a trend which has been widely reported across epidemiological studies. For example, global disability trends indicated by GBD 2017  show that female individuals have had and continue to experience higher levels of disability than male individuals. At the national level, similar trends exists, with older females having a higher prevalence of independent living disabilities (16.4%) compared to males (10.7%) . In Puerto Rico, disparities in independent living disabilities attributed to sex difference is more evident, with an estimated prevalence of 30.7% among females ≥ 65 years compared to 21.4% among male . This disability disparity was even higher in our study group; the prevalence of functional disability among females was 2.70 (IC 95%: 1.4, 5.1) times the prevalence of functional disability among males when adjusting for age, income, chronic conditions, marital status, and sampling design. A consistent female disadvantage in self-care, IADL, and functional mobility domains remained significant even after adjusting for these co-variates, as seen in previous studies [9, 39, 40]. Moreover, within older adults with musculoskeletal conditions with a higher impact on physical function disability (arthritis, low back pain, osteoporosis), the prevalence of physical function disability among female was 2.11 (IC 95%: 1.1,3.5) times the prevalence of disability among males, after adjusting for age, income, marital status, and sampling design. This sex differences could be explained by personal as well as by cultural-related factors concerning gender roles. First, older females from the studied community had a significant higher prevalence of having four or more conditions compared to males, suggesting a poorer functional health status than their male counterparts. Second, there is some evidence supporting that arthritis, osteoporosis, and chronic back pain are more disabling for females than for males [9, 27–30]. It has also been reported a higher incidence, prolonged duration of disabilities, and faster decline in function over time in females compared with males [41–42]. Third, the self-report nature of the data of physical function difficulties in our study raises the question of whether females may have similarly over reported (or males underreported) the levels of difficulties in daily living tasks, as seen in previous studies [43, 44], which may have resulted in false findings regarding sex differences. It has been suggested previously that females may find it more socially acceptable to report disability, whereas males are socialized to ignore them [45, 46]. On the other hand, in a study of sex differences that compared self-reported disability with performance measures concluded that males and females generally report their disabilities accurately, and the higher prevalence of functional problems among females may be a reflection of their true disability status .
Sex inequalities in IADL disability need to be interpreted in light of the gender specific roles and nature of IADLs activities in Hispanic culture. This is, Hispanic male is traditionally the economic provider while the Hispanic female is responsible for the household chores and caretaking roles [47–48]. This is particularly true for the older population of Hispanics. This gender role expectation results in an unequal distribution of household labor, with a higher involvement of females in household chores and preparing meals compared to males  which could in turn plausibly affect females’ physical health resulting in functional disabilities. Moreover, the female role of Marianismo that tends to stress self-denial, encourage females to subordinate their own health and prioritize the care of their family members – meanwhile ignoring signals of pain and illness in their own bodies and delaying medical attention [47, 48].
Further findings from this study suggests that females had higher reported functional disabilities in self-care and functional mobility compared to males, as seen in previous studies [9, 39]. Given that self-care activities (i.e. bathing and dressing) and functional mobility (i.e. walking, climbing stairs, and getting off the toilet) are gender neutral activities, these results may suggest that females are truly at a greater functional disadvantage compared to their male counterparts. These results are consistent with findings among older adults in previous studies [9, 39, 40] and support the hypothesis that a poorer functional health status and a higher impact of musculoskeletal conditions on function among females than males increases the magnitude of the sex gap. This sex gab could plausibly be explained by the impact of gender roles in the performance of daily activities in which women traditionally over-perform gender-specific tasks (e.g. household chores) which in turn may exacerbate chronic conditions such as arthritis, back pain, and osteoarthritis. Further research should be conducted to detangle the effects of sex and gender on functional disabilities.
Considering the greater functional disabilities of females in our study and the compensatory potential of assistive devices to increase older people independence, safety, and quality of life [50–52], this study highlights a finding with important implication concerning the use of assistive devices by females. This is, we should expect greater assistive technology devices (i.e. canes, dressing sticks, or elevated toilet seats) needs and use among women as compared to males, as seen in previous studies [53–55]. Therefore, the findings of this study are of importance for future planning and development of policy to improve assistive technology access, particularly among the most vulnerable population of older women with physical function disabilities living in low-income communities.
Another important finding of this study is the role of the co-variates in altering the magnitude of the association between sex and functional disability within different populations. This is, in a study conducted with 412 females and 328 males residing in underprivileged communities in Lebanon, the magnitude of the association between sex and disability in activities of daily living (self-care), IADL, and physical tasks (functional mobility), was decreased or even non-significant for ADL after adjusting for age, chronic disease risks factors, number of co-morbidities, prescription of medications, level of education, and marital status . In contrast, in our study with an underprivileged community in Puerto Rico, a significantly increase in the magnitude of the association between sex and functional disability resulted after adjusting for age, income, chronic conditions and sampling design. This could be explained by differences in how the adjusted variables were measured. For example, in our study, we adjusted for two groups of co-morbidities (0–3 and ≥ 4) and in the Lebanon study they adjusted for the number of co-morbidities. Moreover, in our study we adjusted for the sampling design, an effect that was not reported on the Lebanon study. Adjustment for age was also different in the two samples (60 years and older in the Lebanon study versus 65 years and older in our study). Therefore, direct comparison of our findings with previous studies should again be undertaken with caution, as different covariates, as well as ways of measuring these co-variates can greatly affect outcomes.
Strengths and limitations
This study has some limitations. First, the use of self-reported data introduces uncertainty about subjective interpretation of the questions. This may be influenced by the interviewee’ understanding of the question, as well as their experiences, expectations, and culture resulting in self-report bias. Therefore, we were unable to confirm actual physical function disabilities. However, studies have shown that self-reported disability is highly correlated with observed
performance on similar tasks with no significant sex differences in reporting accuracy [45, 56]. Second, using a cross-sectional epidemiological design precludes drawing conclusions about cause and effect relationships. Third, due to the COVID-19 pandemic we were unable to recruit the planned sample of 250 participants sample size. However, with this sample size the statistical power of the study was not affected.
The main strength of this study is the use of a population-based study using a random sample of residents in a low-income community. This study examined three kinds of physical function disability- self-care, IADL, and functional mobility. Collecting data from the community allows us to adjust for sociodemographic factors to determine potential confounding variables and modifiers effects. However, a longitudinal study is certainly needed to address health and physical function disability transitions, and the causal relationships between variables.