key: cord-0741850-xlg009wz
authors: Schladitz, Katja; Förster, Franziska; Wagner, Michael; Heser, Kathrin; König, Hans-Helmut; Hajek, André; Wiese, Birgitt; Pabst, Alexander; Riedel-Heller, Steffi G.; Löbner, Margrit
title: Gender Specifics of Healthy Ageing in Older Age as Seen by Women and Men (70+): A Focus Group Study
date: 2022-03-07
journal: Int J Environ Res Public Health
DOI: 10.3390/ijerph19053137
sha: 883896fe262bc6252c2eef71137277babe579e95
doc_id: 741850
cord_uid: xlg009wz

(1) The rising proportion of older adults in the population represents a challenge for the healthcare system. Women and men age differently. This study aims to examine gender-specific characteristics of health in old age from male and female perspectives. (2) Two focus groups were formed in this qualitative study of older (70+) women (n = 10) and men (n = 8) in accordance with the theoretical framework of the World Health Organization (WHO) on healthy ageing determinants. The data were audio recorded and fully transcribed. Qualitative content analysis was performed using MAXQDA. (3) In both focus groups (average age: women 77.1 years, men 74.9 years), gender-specific characteristics regarding healthy ageing were discussed. Women focused on healthy eating, while men focused on an active lifestyle and meaningful activities. Physical and social activities were considered as important for healthy ageing in both groups. (4) Important gender-specific characteristics of health in old age were identified and recommendations for gender-unspecific and gender-specific recommendations were derived. The results provide important information for promoting and maintaining health in old age. Women and men show both similarities and differences in terms of health-related needs and individual experiences. We suggest gender-specific features in nutrition and health programs for older adults.

Due to an increase in the world's demographics, the proportion of adults who are 65 years and older in populations will increase significantly in the next decades [1] . This is expected to raise costs and to pose challenges to the healthcare system [2] . According to the WHO, healthy ageing is defined as "the process of developing and maintaining the functional ability that enables well-being in older age" [3] . The heterogeneous process of ageing includes sex based differences that accumulate over the lifespan and encompass health and lifestyle factors that impact ageing [3] [4] [5] . Women live longer, but report greater impairment in their functional, physical, cognitive, and social abilities [6, 7] as well as in their subjective well-being and physical health [8] . There is also evidence of sex differences in individual dispositions, lifestyle and health behaviors. For example, generally speaking, men are physically more active at older ages, but engage in more risky health behaviors [9] [10] [11] . Some gender differences in health and longevity are preventable and modifiable through interventions and can, therefore, be understood as health inequalities which are "unnecessary, avoidable, unfair, and unjust" and require remedial action [3, 5] . These health inequities between women and men are caused by factors that can be improved. These modifiable determinants include differences in gender roles, health behaviors, and health care delivery [12] . Thus, there is a need for interventions that positively impact these modifiable determinants to create greater health equity.

Little is known about these principally modifiable determinants in old age, as older adults are often underrepresented in research [13] . Therefore, this study investigates agespecific key themes and gender-specific characteristics (both differences and similarities) of healthy ageing from two significant stakeholder perspectives, namely older women and men, and gender-specific recommendations are provided. This study provides answers to the following research questions:

What opinions and attitudes exist about healthy ageing among women and men aged 70 and older? 2.

What gender-specific characteristics can be identified regarding healthy ageing in women and men aged 70 and older? 3.

What gender-specific and cross-gender recommendations for the promotion of healthy ageing can be derived?

This study uses an exploratory qualitative approach employing two homogeneous gender focus groups and is reported according to the Standards for the Presentation of Qualitative Research Results (SRQR) [14] . The semi-structured interview guide was developed in a qualitative research workshop, in which questions were derived deductively based on the WHO theoretical framework on healthy ageing developed by Sadana et al. [5] . This theoretical base combines root causes, structural determinants, intermediate determinants and outcomes, as well as health outcomes of healthy ageing.

To be included in the study, participants had to be to be at least 70 years old and be fluent in German. While "old age" is commonly defined as being 65 years and older [1] , the inclusion criteria began at 70 years old because we were interested in post-retirement experiences in particular. As the typical retirement age in Germany is 67 years [15] , the cut-off of 70 years allowed us to be relatively sure that retirement had already taken place. This way participants had had experience in adapting to new life circumstances and this topic could be investigated.

Participants were recruited from the community in Leipzig, Germany. via the Senior Citizens' Advisory Council of the City of Leipzig and posters in supermarkets, sports clubs and facilities for older adults. Participants were asked to contact the study organization directly by e-mail or telephone if they were interested in participating. Potential participants were sent detailed study information, a consent form, an account data form for the transfer of the expense allowance, and a sociodemographic questionnaire, in advance, by post. Eighteen participants (10 women, 8 men) fulfilled the inclusion criteria and consented to participate. Participants were assigned to the male or female focus group based on gender self-identification.

Participating men were on average 74.9 years old (standard deviation (SD) = 2.8) and participating women on average 77.1 years (SD = 4.1) (see Table 1 ). Sociodemographic data (gender, age, marital and living status, educational level and employment situation) were collected using a short anonymous questionnaire that had been filled out in advance at home. To ensure confidentiality, personalized data were immediately separated from questionnaires and kept separately. 

Two focus groups comprising men (n = 8) and women (n = 10) were conducted in October 2019 in a seminar room at the Institute of Social Medicine, Occupational Health and Public Health in Leipzig. Both focus groups were moderated by a trained scientific research associate who was supported by a research assistant. Each discussion was introduced with a short oral presentation on the topic of health and age.

Both focus groups followed the same general structure. Firstly, the participants were asked about their understanding of healthy ageing. Then, they were asked about basic causes of healthy ageing (biological and social conditions) and about intermediate determinants (lifestyle and health behaviors, individual actions to promote healthy ageing, personality traits, social contacts and the influence of general conditions). As one objective of the study is to derive recommendations for promoting healthy ageing, participants were also asked to discuss structural determinants of health (medical care and public health promotion services). Finally, for each topic block, participants were asked about differences between men and women regarding the respective field.

The group discussions were audio-recorded, fully transcribed and content-analyzed using MAXQDA 2018, according to a protocol for qualitative analysis as outlined by Mayring and Fenzl [17] . Two trained scientific project members with experience in qualitative research independently coded and revised both interviews. The derivation of the coding scheme followed a combined deductive and inductive approach (deductive from the model-based interview guide, inductive from the audio material). Consensus and methodological rigor were established with mutual agreement during the intermediate steps (pre-encoding, revision, recoding and coding) and in a final group discussion. After this, the categories were reviewed, with examples from the transcripts. All codes are provided in Table 2 .

To derive recommendations, two research assistants with qualitative expertise first identified themes. They then matched recommendations to themes, which were specifically mentioned by the participants. Next, a qualitative research workshop was conducted with experts from the fields of psychology, psychotherapy, sociology and nutritional sciences. The expert panel reviewed the topics and the assigned interventions and reached a consensus. Additional interventions were also brought forth and national and local considerations were integrated. The following themes were identified: nutrition, sports, social contacts, preventive health care, lifelong learning, meaningful activity, cognitive skills training, life events, and structural conditions. General recommendations suitable for both genders, as well as recommendations that take gender-specific aspects into consideration, were derived according to the findings. I also go to the gym and exercise for half an hour." SC3: Actions to stay mentally fit W: "But I play poker seriously. The first few years after my retirement, I took courses at the adult education center. A computer course and an English course and such." M: "Intellectual activity is important, as I said. But in my experience, you shouldn't be just killing time with it, so to speak. Whatever it is you do, it should serve some kind of purpose. You should have a task, as they say." SC4: Actions for emotional well-being W: "Yes, I am also a member in two exercise groups and we do a lot of things together. We often go on trips together or have dinner together. We play cards, things like that. We celebrate milestone birthdays." M: "As I said, you have to create a hobby." SC5: M: "It is certainly important to make a difference between medication for older and younger people ( . . . ) In many cases it has been found to be wrong. And differentiating between medication for women and men, which is also not being done." SC3: Sports W1: "I always went to rehabilitation sports, I must say. And there it was nowhere near as full as there." (W1: "Well, but you go to the group?") "But yes." (W1: "Once only?") No, I go to three groups." (W1: "That's nice.") "And so, three times, of that I do twice in a row and another day the third group, that I don't have to go there three times a week. That would be too much. But going twice is fine." M: "Regarding dancing in general, it's usually the women who are best. In square dancing, it's the men. Why is that? I was quite surprised when I took a closer look at this phenomenon, that in the beginning women predominate. And the better my 

The key results are presented below (for detailed results see Appendix A). The participants discussed the meaning of healthy ageing, lifestyle and health behaviors, individual actions to promote healthy ageing, the influence of personality traits, the role of social contacts, structural conditions, life incidents, biological factors, medical conditions, health care and public health promotion services, and public infrastructure.

Women expressed a generally positive attitude towards ageing and emphasized that the perception of old age has changed significantly in the last decades: For men, ageing was associated with disease and struggle: "Yeah, you're certainly aware that in old age you will always have little aches and pains, sometimes maybe something worse too".

Both emphasized that being proactive and optimistic as well as to adaptive to changes due to ageing were important: "I noticed with a friend that he became a bit frail and then began having difficulty walking. And then he stopped walking altogether and it continued in this way, and then he was dead. Yes, it happens very quickly at a certain age. And I think you should try to avoid that. Don't give up, but fight. Fight every day".

According to all participants, healthy ageing has genetic components, but one's own actions can influence the course of ageing to a great extent.

"Of course, staying healthy is partly down to your genes. But I do think it's important to take a lot of initiative yourself". In contrast, men focused on an active lifestyle and meaningful activities: "Intellectual activity is important, as I said. But in my experience, you shouldn't be just killing time with it, so to speak. Whatever it is you do, it should serve some kind of purpose. You should have a task, as they say".

(male participant) Social activities, including intergenerational contact, were considered important for healthy ageing by both women and men:

"Of course, the social environment is important. So many of us, I, in particular, sit at home alone all week without any contacts at all. There's a nice saying: take time for your friends, otherwise time will take your friends".

(male participant) However, from the perspective of both genders, maintaining and cultivating social contacts was easier for women:

"Well, there are big differences. We are simply socialized differently, we women. We are more communicative, we are more open. And the men, they withdraw".

Physical activities were considered important by both groups, but women and men described different motivations for exercising and doing sports. Women associated sports with social interaction, fulfilling leisure activities, and maintaining well-being:

"Yes, I am also a member in two exercise groups and we do a lot of things together. We often go on trips together or have dinner together. We play cards, things like that. We celebrate milestone birthdays".

In contrast, men were motivated by generating a "sense of achievement" and preventing diseases:

"Until my heart attack about 20 years ago, I used to drive to the bakery. I didn't get any exercise at all. I hated exercise. I still hate it, but I do it. I go to a cardio class once a week. I also go to the gym and exercise for half an hour".

Women and men generally rated health care conditions as essentially positive. This is evident in the responses given by the participants: "Our healthcare system is actually excellent, I would say. We really can't complain about it. We live in luxury here" (female participant). "And I can't complain at all. It's all going well as far as medical care is concerned".

All participants say they took advantage of preventive checkups. Nevertheless, both wished for more preventive services for older adults. Mammograms for women over 70 years old was specifically mentioned since this screening is not supported by health insurers. Similarly, older people are excluded from other preventive health services which promote well-being and health instead of focusing on pre-existing diseases and physical consequences of aging, as can be seen in this example: "Yes, because everything comes to an end at 70. No more gynecological checkups, nothing. You've taken advantage of all the preventive services. But that's all gone".

Men emphasize the need to differentiate between genders and age groups when it comes to medical care and medication:

"It is certainly important to make a difference between medication for older and younger people ( . . . ) In many cases it has been found to be wrong. And differentiating between medication for women and men, which is also not being done".

For women, caring for relatives and the death of significant others were discussed as elemental experiences of old age:

"Most often you're caring for your spouse, or you're having to deal with the fact that the end of your spouse's life is not far off. That's quite a challenge".

Men considered retirement to be a particularly critical life event:

"You can read about it, it's typical for men of retirement age. And as I said, I had a hard time coping. But thank God, with social support and also the help of my family, I've made it through so far". Women stated that they benefit from contacts with neighbors but felt that some of these contacts were diminishing: "People walk up the stairs and disappear into their flats. With some I even have the impression that should I open my door, they would quickly close theirs. That has changed a lot".

Men focused more on insufficient transportation: "And yes, well, I still like driving. But I would also be happy if public transportation were good enough to allow me to leave the car at home more often".

Both women and men also considered the pursuit of hobbies and adult education to be an important prerequisite for healthy ageing, as can be seen in this example: "But I play poker seriously. The first few years after my retirement, I took courses at the adult education center. A computer course and an English course and such". Men expressed the wish for specific offers for male older adults, as existing offers were often perceived to be aimed to a female target group:

"But what I'm trying to say is that something probably needs to be done because, on average, we men are being forgotten. There are a lot more opportunities and things for women. There's this and there's that. Men have other interests, generally speaking".

(male participant)

A guiding principle of recommendations should be to use the potential of older people by integrating their experience and resources (e.g., their skills earned in their professional life and through their hobbies, or their free time). Offers for older adults should ideally emphasize reciprocity by providing win-win situations for children, adolescents, younger and older adults (e.g., homework help, repair cafés, coaching a sport, or other intergenerational offers). Many recommendations (e.g., soccer coaching for children by a retired coach or involvement in neighborhood gardens) have the potential to address many purposes at once (e.g., performing a meaningful task, strengthening social integration, promoting one's own physical activity). Offers gain acceptance and effectiveness the more specific they are to regional characteristics (e.g., senior afternoons with local crafts or cooking evenings with local and seasonal specialties). Further considerations include: the degree of urbanization vs. rurality (e.g., what kind of cultural preferences are common in the place? What are the transportation options? Do older adults need pick-up and shuttle services?) and gender specifics (e.g., offer not only handicraft arts, but also craftsmanship afternoons; target men and encourage their social activity; offer workshops on cooking specifically for men who often have not learned to cook). For an overview of the recommendations, see Table 3 . Provide information about existing services in the region via print and digital media directed toward older adults (e.g., in daily newspapers, city magazines and local newspapers, with posters in supermarkets and flyers in mailbox, and via local radio and television)

Consideration of gender-specific characteristics: since there are different motivations for participating in sports programs (women: "do something for myself" vs. men "sense of achievement"), this should be taken into account when creating and advertising sports programs Offer cultural events that are free of charge or low cost (e.g., "senior citizen discount"; "pay what you can"-admission fees; local sponsorships) • Promote initiatives to encourage neighborly contact and neighborhood assistance (e.g., neighborhood groups in social networks; multigenerational houses/centers; "Schwatzbank"/"Chat bench" at public places = bench with a sign indicating you would like to have a chat with a seat neighbor) Table 3 . Cont.

• Create special opportunities to maintain mobility for older adults, especially in rural areas (e.g., "Mitnahmebank"/"modern hitchhiking" = bench with a sign indicating a person would like to be given a ride; communal or private shuttle services to institutions, shopping halls or cultural places)

In both focus groups, participants were heterogeneous in their age distribution and therefore part of different age cohorts. The youngest had not had personal childhood experiences during World War II, while the oldest in the group had experienced years of childhood and adolescence socialization during the National Socialist dictatorship. Nevertheless, all study participants had experienced incisive social upheavals including various forms of government, comprehensive changes in gender roles, significant medical progress and modifications in the concept of old age. This historical context, in conjunction with the broad age distribution, could presumably inform very different attitudes toward healthy aging [18] . These cohort differences could not be explored further in the context and analysis of the group discussion but should be kept in mind when drawing conclusions.

The aim of this qualitative study was to identify gender-specific characteristics of healthy ageing and to derive recommendations to promote positive health attitudes and behaviors. The topics and needs mentioned are consistent with most of the research literature on healthy ageing (e.g., [19] ). However, in contrast to previous research by Bryant et al. [20] , female participants in our study expressed a more positive image of the ageing process compared to men, who primarily associated ageing with negative consequences. This should be addressed in gender-specific offers (e.g., gender specific nutrition courses for men who want to learn to cook healthily after the death of a spouse; or projects such as neighborhood gardens and repair cafés, which could be more attractive to older men than the existing offers that can sometimes be perceived as more appealing to women). A positive image of ageing is an important psychological resource in assessing life satisfaction. Further, self-perceptions of ageing influence the success of health-promoting programs [21] [22] [23] [24] . Therefore, psychoeducational programs on age-related biological, psychological, and social change can positively influence the image of ageing and potentially improve functional health [25, 26] .

Although all participants agreed that biological factors had an influence on ageing, women and men agreed that nutrition (e.g., eating fruits and vegetables, cooking at home, limiting alcohol), exercise (e.g., rehabilitation sports, walking), and mental activities (e.g., reading, sudoku) play an important role. Further, older adults actively contribute to healthy ageing and reduce the negative effects of aging by eating healthfully, maintaining an active lifestyle and keeping mentally fit, as is consistent with the findings from Harmell et al. [19] . Our study participants emphasized the need to adapt to changes in health and to remain active. This attitude of actively taking part in a healthy ageing process sets the stage for successful programs. Initiatives to promote healthy ageing should integrate gender-specific aspects and generate social contacts at the same time. Both women and men regarded maintaining and generating social contacts as important for quality of life in old age, but assumed that this would be easier for women, which is in line with existing research [8] . In addition, contact with younger generations was seen as a supportive resource in ageing, in accordance with Teater [27] . Gender-specific aspects should be included; special offers for men should be created. Recommendations to promote social contacts for older adults could, likewise, be based on cultural, intellectual, athletic and voluntary activities. The positive impact of meaningful activities was particularly emphasized by the men in our study, which is consistent with findings from Hajek et al. [28] , who emphasize the positive effect of volunteering on well-being.

Study participants reported different motivations for exercising: older men focused on improving their performance and preventing diseases, while older women wanted to maintain mental and physical fitness for their own well-being (to do "something for themselves"). Empirical research on gender-specific motivation for physical activity is still deficient and includes open questions (e.g., [29, 30] ); however, for both genders, social interaction as well as enjoyment of the activity appear to be greater motivators than performance goals, when compared with younger age groups [31, 32] . Programs to promote physical activity should address both motivations, offer a pleasant atmosphere, create individual health benefits, and provide opportunities for social exchange [29, 33] .

Although women and men were very satisfied with health care, they wanted more preventive services, which is contrary to the state of research with regards to men [34, 35] . Further, men wanted gender-specific aspects to be considered by physicians when prescribing a medication and determining its dosage. Thus, drug approvals and their associated studies should consider gender-specific differences (e.g., are some medications more effective in a male body, or do men need a higher dosage than women).

Targeted offers could support older adults in coping with critical life incidents. For women, illnesses, caregiving and the death of relatives is particularly impactful, in line with the research of Stein et al. [36] . For men, retirement plays an important role.

There was agreement between both women and men that environmental conditions are important in ageing. Although all participants lived in an urban area, they reported that in rural areas older people experienced limitations in mobility, health care, and cultural, sports and social opportunities, thereby hindering healthy ageing. Unfavorable environmental conditions also prevent older adults from engaging in physical activity [29, 33, 37] . When designing programs, accessible and barrier-free locations and age-appropriate times of day should be taken into account [38] . Consistent with Paz et al. [39] , interviewees emphasized that participation in activities requires sufficient financial resources. Thus, offers should cost as little as possible or be free of charge [33, 37] .

A strength of this study is the focus on women and men 70+. Older people are underrepresented in empirical research due to recruitment and participation problems [40, 41] . There are also some limitations due to sample size and selection bias. Participants who agreed to participate in the study may have had a high interest in the topic of healthy ageing. Therefore, sample selection effects cannot be completely ruled out. Since socio-economic status was not assessed, it was not possible to obtain an overview of the participants' financial situation. Assessments and recommendations may, therefore, be limited. Although some of the participants have had previous life experiences in a rural area, as well as acquaintances and relatives there, they all now live in an urban area. The perspective of rural seniors has, therefore, not been sufficiently taken into account. Also, by requiring sufficient German language skills to participate in the discussion, migrant and minority ethnic groups were not represented and generalizability is also limited in this regard.

The current study provides important implications for practice and care offers. As the perception of ageing has improved over recent years, especially for women, these gains should be extended to men. Ageing could be embraced also by men, as a phase of life full of opportunities. In developing programs, the need for intellectually stimulating and meaningful activities and for (intergenerational) social contact should be addressed and possible side-effects emphasized (e.g., the possibility of building up social contacts while engaging in physical activities). Gender-specific needs and age subgroups in the elderly population also need to be considered in medical care.

Significant research implications also emerge. Recommendations developed in this study were guided by the principle that they should be based on the needs of the com-munity. These recommendations should be further developed and analyzed concerning their acceptability, feasibility, and effectiveness. It would also be interesting to examine whether the same views, needs, and requirements for recommendations would emerge from a rural sample or among adults 70+ from migrant or other minority groups (with group discussions in other languages). Since men often seem to perceive existing services and programs for older adults as women-specific, research should explore what offers men would like to see and how existing offers can be improved so that they also feel addressed. As the focus group discussions took place in October 2019, prior to the COVID-19 pandemic, it would be of great interest to investigate possible changes in attitudes toward healthy aging and implications for recommendations in a follow-up study. Funding: This work was funded by the German Federal Ministry of Education and Research, grant numbers 01GL1714A, 01GL1714B, 01GL1714C, 01GL1714D and is part of the study "Healthy Aginggender specific trajectories into latest life (AgeDifferent.de)". The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We acknowledge support from Leipzig University for Open Access Publishing. Members of the AgeDifferent.de study group: Steffi G. Riedel-Heller (Principal Investigator), Franziska Förster, André Hajek, Kathrin Heser, Hans-Helmut König, Wolfgang Maier, Alexander Pabst, Elzbieta Buczak-Stec, Michael Wagner, Birgitt Wiese.

The study has been approved by the Ethics Committee of the Medical Faculty of the University of Leipzig (AZ 485/18-ek). All participants were provided with written and verbal information about the content and gave written informed consent to participate.

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement: All data generated or analyzed during this study are available from the corresponding author on request.

Women: A healthy lifestyle (including a healthy diet, physical and social activities, regular medical screening and learning new content) contributed to healthy ageing. Men reported caring less about healthy eating, relying on women in this regard.

Men: The male participants emphasized that being proactive was important. Maintaining physical and mental activity, as well as hobbies and meaningful tasks, were essential for healthy, active and independent ageing. After retirement, hobbies helped to structure leisure time, providing motivation, a sense of achievement and positive social and cognitive effects. Social contacts were important for an active lifestyle, as they encouraged leaving the house and were a source of inspiration for activities. The topic of nutrition was brought up to a lesser extent. It was perceived as important to be moderate in the amount of food and alcohol consumed. Smoking was rated as harmful for health. In their opinion, women maintained a more active lifestyle and were more motivated to live healthily.

Women: Healthy ageing was reported to be strongly dependent on one's own actions. There was a desire to maintain functional abilities for as long as possible, in order not to become a burden on relatives. The female participants wanted to maintain mental and physical fitness for their own well-being, and they suspected that men were primarily motivated to keep an active lifestyle by performance goals. They repeatedly emphasized the high relevance of taking the initiative in maintaining social contacts. Exercising (e.g., hiking, swimming, rehabilitation sports, gardening or walking the dog) and intellectual activities (e.g., conversation groups and literature circles) were further seen as opportunities for social exchange. Female participants perceived major gender differences in social behavior due to socialization. In their opinion, men had more difficulties in making new friends and engaging in activities. Furthermore, they assumed that men were more reluctant to ask for help. In addition, it was observed that places where male social life used to take place were now disappearing (e.g., regulars' tables in pubs).

Men: Physical activities (e.g., dancing, cycling, bowling and rehabilitation sports) were not primarily seen as a pleasure, but as serving a specific purpose (e.g., fighting illness) or being helpful for the achievement of a certain goal (e.g., having a sense of accomplishment). The male participants could increase their motivation for activities by setting goals for themselves, generating "feelings of success" and giving their everyday life a sense of purpose. Meaningful activities that had positive effects on the activity level in old age were seen as important. There was also consensus that a social network needed maintenance and cultivation. Mental and physical activities were seen as social benefits. Men reported having more motivational problems than women in creating an active everyday life, including physical, cultural or social activities, after retirement. Women generally had a higher activity level.

Women: It was assumed that optimistic and open-minded people find it easier to cope with the process of ageing. In addition, these personality traits also facilitated getting to know people and building up a comprehensive social network in old age. In contrast, anxiety was reported to interfere with independent ageing by setting limits to oneself. There was consensus that older men were more often seen as pessimistic and reserved.

Men: A positive attitude towards ageing was perceived as central to healthy ageing. It also facilitated dealing with health impairments and led to a more active lifestyle. Optimism was seen as a modifiable attitude that could be increased through effort and practice. According to male participants, women were generally more open-minded and more capable of dealing with frustrating experiences.

Consensus: Both focus groups ("men" and "women") agreed that a genetic predisposition had a certain influence on health and the quality of ageing, e.g., having a genetic predisposition to certain diseases.

Women: Female participants emphasized that, despite a genetic predisposition, one's own initiative to stay healthy was important.

Men: Male participants saw differences in the genetic constitution of the sexes: e.g., the life expectancy of women was higher due to genetics. In their opinion, women also had healthier lifestyles as compared to men. On the other hand, the athletic performance of men was estimated to be higher compared to that of women.

Women: According to female participants, being ill increased the risk of loneliness. In particular, serious and chronic illnesses were linked to reduced visits from friends. Healthy old people would prefer not to think about future illnesses or their own death.

Men: Male participants reported a negative impact on quality of life due to illness as most of them had already experienced a severe illness. In their mind, diseases had a negative impact on physical fitness and resulted in a negative view on life. In addition, dealing with or fighting illnesses was experienced as dominating daily living and limiting opportunities. Nevertheless, for several subjects, the onset of illness led to a healthier lifestyle (e.g., more exercise).

Consensus: In both focus groups, health care was rated positively in general. Women and men both desired preventive health care.

Women: Female participants were aware of the health screening options and vaccination offers. They complained that mammography screening after the age of 70 was no longer free of charge and that the communication between specialists and general practitioners was often inadequate. Legal euthanasia was discussed as desirable option. According to participating women, men were more likely to be urged by their spouses to attend preventive checkups.

Men: According to male participants, preventive check-ups were attended regularly. It was criticized that some medical services seemed to be dependent on patient status (regular vs. new patient). Better advice regarding alternative medicine (homeopathy) as well as free health check-ups when changing medication were desired. The prescription and dosage of medications was criticized as not being differentiated according to age and gender. The high volume of patients seen by physicians and, as a consequence, difficulty in obtaining doctor's appointments were perceived as problematic.

Women: Female participants regularly used public health services (e.g., health centers, swimming pools) and cultural offers for older adults (e.g., adult education center, senior academy of the university, new media courses) and evaluated them positively. They criticized the inefficient capacity utilization of both swimming pools and fitness centers: due to a lack of staff, facilities remained closed, although swimming was a sport for every age group.

Men: Male participants also used health sport offers, but more out of a sense of duty than as recreational pleasure. Sports offers for the male target group were rated as positive. Men would also make use of cultural offers and opportunities for education. That many sporting and cultural activities for older adults were addressed toward women was criticized, and men stated that they would prefer more "male-oriented" offerings, such as repair workshops.

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Perspektiven und Probleme bei Surveybefragungen mit alten Menschen

We would like to thank all participants of the focus groups for their cooperation.

The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Appendix A.1 MC1 Meaning of Ageing Women: Despite the consensus between both groups that the process of ageing was challenging, the female participants expressed a generally positive attitude towards ageing. They emphasized that the idea of old age had changed massively within two generations and that people were still fit and agile at the age of 70 to 80. Healthy ageing was associated with healthy nutrition, exercising, and an active and social lifestyle. Social exchange and integration as well as openness to new things (lifelong learning, getting to know people) were important.Men: Among the male participants, ageing was associated with disease, survival, and struggle. Good and healthy ageing was associated with self-determination, limited disease and a painless death. In general, ageing meant adapting to the current state of health and making the best of it. Meaningful activities that had positive effects on the activity level in old age were important.

Women: Female participants differentiated between types of social contacts (e.g., old and new friendships, family, and neighborhood) to a greater extent compared to male participants. Old friendships from school days were considered important for a sense of community and support. Furthermore, women considered getting to know new people as important. Contacts with peers of the same age were important because they similarly understood age-specific problems, while being in touch with younger people was inspiring. Female participants further reported fewer contacts without any emotional benefit. In general, openness and individual initiative were considered as central for establishing and maintaining social contacts. In case of an emergency, old friends and family members were considered to be major sources of support, while more recent acquaintances were considered less reliable. According to female participants, there were significant differences between the sexes in terms of social competence: men had difficulties in accepting social support and in making new contacts.Men: Male participants appreciated social contacts and considered these stimulating and meaningful. However, fostering social contacts was often difficult for men. Meeting people of other age groups, especially younger people, was considered important. Family members were seen as an essential source of social support in times of need. Spouses typically motivated men to engage in activities. According to male participants, ageing men were more likely to withdraw and to become lonely. In their judgement, women were able to make new social contacts more quickly after social losses.

Consensus: Both focus groups equally ("men" and "women") perceived differences for older adults when comparing urban and rural areas regarding general external conditions. Rural areas were associated with poorer conditions regarding medical care, mobility, social and cultural offers as compared to urban areas, especially in comparison to "the past". The possibility of being mobile without car by means of public transport was emphasized as a great urban advantage compared to rural life. On the other hand, more deep-rooted social interactions were an advantage in rural areas.Women: The female participants reported diverse experiences regarding neighborhood relations in the city. In some cases, relationships with neighbors were considered anonymous, while other women reported good neighborly relations in their residential building. Good neighbor relationships were described as having been self-initiated and important to subjective well-being. The participants mentioned that financial hardship contributes to poor conditions for healthy ageing. In addition, when financial resources were low, financial support of family members was considered to be more important than cultural attractions.Men: For male participants, neighborhood relations did not play a central role. They emphasized mobility as highly relevant: driving a car was associated with independence, and thus giving up a driver's license was seen as a loss of autonomy and sovereignty. Better public transport connections were also desired. They criticized that there were increasing difficulties in finding volunteers for voluntary work. Here, financial interests would increasingly impact commitment.

Women: Both caring for and the death of a close relative were described as very emotionally and physically stressful events. Furthermore, these life events reduced social contacts and support. According to the participants, men would show problems in opening up to offers of support.Men: According to male participants, retirement represented a crisis for the individual, which could be accompanied by psychological instability (depression) particularly in men.