Women and sex-specific health research in the German Society for Social Medicine and Prevention

Since the 1970s women's health research has put gender-specific topics on the agenda of health research and practice. Based on a social science approach, it focuses on social conditions of the maintenance of women's health and of their needs in prevention, health promotion, medical treatment, and rehabilitation. Besides an analysis of woman-specific topics (such as sexual violence or drug abuse) women's health research addresses questions of gender bias in health research. In Germany, guidelines are lacking that ensure appropriate attention to gender issues for health research. The section "Woman-specific and gender-specific health research" of the German Society for Social Medicine and Prevention (DGSMP) intends to intensify the discussion on the gaps in health research and prevention and on the development of guidelines to detect gender bias. The main goal is to implement the concept of gender mainstreaming in public health.     

Diversidad afectivo-sexual,corporal y de género más allá del binarismo en la formación en ciencias de la salud

Health systems and professional training are based on gender binarism. At different stages of the life cycle, there are situations that cause inequities, lack of opportunities and risks to the health of lesbian, gay, bisexual, trans and intersex (LGBTI) people. This work aims to explore the need to include affective-sexual, bodily and gender diversity (ASBGD) in the curricula of health sciences degrees. A narrative bibliographic review was performed to identify recommendations based on international frameworks and experiences with new approaches to incorporate ASBGD, as well as a critical analysis of the current situation regarding the deficiencies in the inclusion of ASBGD in health sciences degrees. At present there is a progressive inclusion of ASBGD in health sciences in many countries, which is considered fundamental for ethical professional practices, and excellence in care. We offer a summary of advances, emerging debates and teaching strategies for the inclusion of ASBGD from previous international experiences. These experiences highlight the need for inclusion of ASBGD, the lack of knowledge about specific needs of LGBTI people and the benefits of breaking with the binary imposition. They recommend increasing knowledge about terminology, rights and inequalities, and the active participation of LGBTI people and communities.     

Gender in der Epidemiologie

Against the background of sex-specific and sex-comparative approaches in health research, this article aims to clarify to what extent the category sex/gender with its biological dimensions (sex) and social dimensions (gender) has systematically and conceptually been consider ed in epidemiology and which methods have been developed. Epidemiologic research has been criticized for routinely controlling statistically for age and sex but often ignoring aspects of gender. Inadequate consideration of sex/gender may result in systematic errors (gender bias), on the one hand, if sex/gender is ignored as an important variable, and, on the other hand, if differences between men and women are assumed when there are actually similarities. There are examples of adequate consideration of gender in exposure assessment, analysis of social position or modelling of interactions in current articles of scientific journals. How ever, epidemiologic reference books and textbooks as well as university training in epidemiology show that the category sex/gender has not been integrated with both dimensions sex and gender into the currently predominating thought style of epidemiology. For the further development of valid epidemiologic research clarification of terms, generation of unambiguous concepts and sophisticated statistical tools are necessary. This is the only way to succeed in analysing the complex interactions between sex-linked biology and gender relations.     

An hermeneutic approach to health-disease relationship

This work aims to contribute to the current discussion on the relationship between health and disease, taking a hermeneutic perspective on the issue. The first section, referring to the discussion among the hermeneutic, phenomenological, and existential lines of philosophy, analyzes the work of two philosophers, Kierkegaard and Heidegger, who profoundly influenced contemporary hermeneutics. The article discusses the concept of anguish, which for Kierkegaard (contrary to the biomedical approach) is a constitutive component of human beings: for Kierkegaard, as subsequently for Heidegger, anxiety is not a pathological symptom but a state that allows for privileged access to self-knowledge. In the second section, we approach how hermeneutics, and especially the work of Gadamer, developed the concepts of health, illness, and suffering; we also analyze how in recent years this perspective has influenced the social sciences (and particularly medical anthropology) in their approach to health problems. The third and final section discusses the implications of hermeneutics for clinical training and practice, demonstrating the applicability of Heidegger's and Gadamer's thinking for work by physicians and nurses.     

The health belief model and preventive health behaviour in Singapore

Every theoretical model in the social sciences confronts a common challenge: to maintain its explanatory power in different cultural contexts. This is, of course, only one of many challenges faced in theory building. But, this discussion shall focus only on the possibility of a cultural bias. More specifically, the aim of this paper is to discuss some of the findings from a test of the Health Belief Model (HBM) in a multi-ethnic society, Singapore. The HBM is a theoretical framework frequently used in the analysis of health-related behaviour. The discussion will be divided into four sections. The first section will present briefly the components of the HBM. The second section will summarize the procedure used to conduct the empirical test of the HBM. And the third and final sections shall deal with the comparison of preventive health behaviour among three ethnic subpopulations in Singapore, highlighting the main findings of the test of the HBM.     

Alternative models for the epidemiological analysis of obesity as a public health problem]

Public health problems have been analyzed over time using different approaches involving a variety of methodological and theoretical models. The classical epidemiological model and the social epidemiological model are two examples of models used in public health research. Although each of these models covers a whole range of public research approaches, it is possible to identify the different theoretical and methodological criteria and the different ideological assumptions on which they are based. The objective of this article is to make a comparison of the criteria used by the classical and social epidemiological models in the study of public health problems, with special emphasis on the study of obesity. This comparison shows that the knowledge generated by studies carried out under each of these models is rather different, as an effect of the different theoretical, methodological and ideological criteria used by each model. However, far from being contradictory, the knowledge generated by each model can complement that generated by the other. Finally, the inclusion of social sciences as a tool for the analysis of public health problems, specifically the problem of obesity, is discussed.     

¿Se puede evaluar la perspectiva de género en los proyectos de investigación?

Objective

Gender perspective is a theoretical approach that developed from feminist theories and whose main focus is the analysis of gender inequalities. Integration of this perspective is central to promoting equity in health. The aim of our study was to devise a protocol/questionnaire to assess whether gender is present in research projects and thus help to fill the gap in assessment tools.

Methods

We used a qualitative design with two techniques: group discussion and expert group meetings. The discussion group conducted a dialectical analysis of the basic concepts in research and gender and integrated the results of the discourse produced in the expert group meeting. The drafting of the protocol was organized around the pertinent questions that should be asked at each stage of a research project.

Results

The protocol consists of 15 questions: four in the introduction section, two in goals and hypotheses, three in methodology, three in purpose of the study and three to be implemented throughout the research project.

Conclusions

The protocol identifies projects that include a gender perspective. Use of this protocol will improve the quality of research and will help to reduce gender inequities.     

Concepts in social research: links with the field of health services evaluation

This paper discusses theories and research perspectives from the social sciences and their role in constituting the field of "health services evaluation". The objective is to present less explored theoretical fields such as the "comprehensive" and "dialectical" approaches. Finally, the study presents a methodological proposal based on a qualitative approach to the evaluation of health services and projects.     

Sexing the baby: Part 2--Applying dynamic systems theory to the emergences of sex-related differences in infants and toddlers

During the first three years of life, children acquire knowledge about their own gender and the gendered nature of their environment. At the same time, sex-related behavioral differences emerge. How are we to understand the processes by which bodily differentiation, behavioral differentiation and gendered knowledge intertwine to produce male and female, masculine and feminine? In this article, we describe four central developmental systems concepts applied by psychologists to the study of early human development and develop them in enough depth to show how they play out, and what sort of knowledge-gathering strategies they require. The general theoretical approach to understanding the emergence of bodily/behavioral difference has broad applicability for the health sciences and for the study of gender disparities. Using dynamic systems theory will deepen and extend the reach of theories of embodiment current in the health sciences literature.     

The Inexorable Rise of Gender and the Decline of Sex: Social Change in Academic Titles, 1945–2001

More than 30 million titles of "academic" articles, from the years 1945-2001, were surveyed for occurrences of the words sex and gender. At the beginning of this period, uses of gender were much rarer than uses of sex, and often used in the sense of a grammatical category. By the end of this period, uses of gender outnumbered uses of sex in the social sciences, arts, and humanities. Within the natural sciences, there was now more than 1 use of gender for every 2 uses of sex. The beginnings of this change in usage can be traced to Money's introduction of the concept of "gender role" in 1955 (J. Money, 1955). However, the major expansion in the use of gender followed its adoption by feminists to distinguish the social and cultural aspects of differences between men and women (gender) from biological differences (sex). Since then, the use of gender has tended to expand to encompass the biological, and a sex/gender distinction is now only fitfully observed.     

Different wor(l)ds: three approaches to health research

This article describes three approaches to research in the social sciences: positivist, interpretivist and critical social science. It uncovers some of the philosophical assumptions these approaches adhere to and situates the discussion in the population health arena with respect to these assumptions. The issues under debate are as yet unsolved (and perhaps unsolvable), with long histories in philosophy and sophisticated rationales on all sides. The article advocates defining the underlying terms of discussion and making assumptions explicit to facilitate dialogue, and also encourages exploration of and tolerance for other approaches.     

Defining,conceptualizing and characterizing racism in health research

The examination of racism as a determinant of health is an emerging area of research. This paper examines and expands on existing research approaches in relation to three levels at which coherence and conceptual clarity can be improved: in defining and theorizing racism, in conceptualizing how racism may relate to health and in characterizing racism as an exposure that can be operationalized and measured. A definition of racism in relation to the broader concept of privilege/oppression is detailed along with a discussion of the implications of this definition in relation to the concept of power, the perpetration of privilege/oppression, intention vs. effect and objective vs. subjective racism. This is followed by a conceptualization of the relationship between racism and health, which incorporates both previous approaches in health research and pertinent social theory and is designed to aid in organizing and synthesizing knowledge, defining concepts and variables, generating specific research questions and determining appropriate analytical approaches. The range of dimensions across which perceived racism (as experienced by oppressed racial groups) can be characterized, operationalized and measured as a health-risk condition is then detailed. It is hoped that through improved conceptual and theoretical tools this nascent area of study will be better equipped to explain how racism relates to the distribution and determinants of population health. Such improved knowledge will better guide policies and actions aimed at improving the health of those who suffer from this invidious phenomenon.     

Embedded gender and social changes underpinning inequalities in health: An ethnographic insight into a local Spanish context

Despite growing interest in the social determinants of health and contributions from studies focussing on the analysis of explanations to enhance our understanding of the interactions between gender identities, embodied experiences and structural inequalities between men and women, few research papers have devoted attention to this perspective in the Spanish context. This study is an empirical exploration of lay knowledge, for an enhanced understanding of health inequalities in this context, from an ethnographic standpoint based on a phenomenological approach. Specifically, our aim is to study the lay perceptions of men and women regarding their gender identity and living conditions as health determinants within different "contexts" of their everyday lives, namely: the personal context; the home context; and the neighbourhood context. Fifty eight in-depth interviews and three focus groups were held between January 2005 and January 2007, and analysed using a hermeneutic method. Our findings show how disease-coping strategies or the perceived loss of social cohesion are linked to the gender system. They also point to how the dynamics of social change have developed around a strong division between the productive and reproductive arenas. Approaching these issues from different "contexts" provides insights into the explanations for the gendered patterning of mortality and morbidity, as well as furthering our understanding of the basis for social embodiment of gender differences and health inequalities in the context studied. In the discussion of our findings, we place emphasis on the implications that informal caring has for these processes and also take into account contributions of the "lay approach" to study and understand social determinants and health inequalities.     

Lay people's evaluations of health: are there variations between different subgroups?

STUDY OBJECTIVE--To elicit lay concepts of health and to see whether these are related to various sociodemographic factors, as has been suggested by previous smaller studies. DESIGN AND SETTING--A total of 196 people aged 18 and over were selected, as a representative sample of the general population, from the electoral registers of Walsall and Dudley in the West Midlands. Respondents were interviewed in their own homes in the autumn of 1989. MEASUREMENTS--Open ended and structured questions were used to elicit concepts of health. The three main stages consisted of an unprompted section in which respondents were asked to describe the features of good or poor health in themselves or others; a prompted section in which they were asked to rate 37 health statements using a series of categories from "very important" to "not at all important"; and a section in which they were asked to indicate which of six groups of statements, each representing a particular concept of health, best represented their own notions of health. RESULTS--Health was seen as multidimensional. Irrespective of whether respondents addressed health in self or health in others, or good or poor health, the biomedical dimension remained an important one. The manner by which concepts of health are elicited may provide some explanation as to why so many and varied concepts are alleged to be held by different subgroups of the population (notably different social classes). CONCLUSIONS--The differences found in this study between models of health employed by different subgroups of the general population have not been as great as has previously been suggested in the published reports. This is encouraging for those using existing health status measurements.     

Chile: social protection in health]

This piece begins with a brief discussion of the concepts leading to the social right to health protection. Special emphasis is placed on the principle of social cohesion, which has influenced social health protection in European countries. Chile's experience in this field from the 1990s to the present is described, as exemplified in three dimensions. In the first place, social security coverage is presented as a means to achieve universal (horizontal) coverage. A discussion follows on vertical coverage, where the author identifies health problems for which insured persons have guaranteed rights of access to medical care. This section describes available emergency care, primary health care, and the special plan for Universal Access to Explicit Guarantees (Acceso Universal de Garantías Explícitas de salud, or AUGE). Thirdly, the discussion covers the funding sources supporting the Chilean health care system: Government subsidies, contributions to social security, and out-of-pocket disbursements for private care. Chile's public health system has various special programs. One of them is catastrophic insurance, which covers 100% of the care needed for complex and very costly treatments. Older persons (over 65) have coverage for 100% of the cost of eyeglasses and hearing aids, and for 50% of the cost of home care. If life expectancy is an appropriate indicator of health system results, it is worth noting that Chile and the United States of America have both achieved a life expectancy of 77 years, even though Chile spends only 5.9% of its gross domestic product on health care, as compared to the 15% spent by the United States.     

Socioeconomic inequalities and mental health problems in children and adolescents: A systematic review

Socioeconomic inequalities in health are an important topic in social sciences and public health research. However, little is known about socioeconomic disparities and mental health problems in childhood and adolescence. This study systematically reviews publications on the relationships between various commonly used indicators of socioeconomic status (SES) and mental health outcomes for children and adolescents aged four to 18 years. Studies published in English or German between 1990 and 2011 were included if they reported at least one marker of socioeconomic status (an index or indicators, e.g., household income, poverty, parental education, parental occupation status, or family affluence) and identified mental health problems using validated instruments. In total, 55 published studies met the inclusion criteria, and 52 studies indicated an inverse relationship between socioeconomic status and mental health problems in children and adolescents. Socioeconomically disadvantaged children and adolescents were two to three times more likely to develop mental health problems. Low socioeconomic status that persisted over time was strongly related to higher rates of mental health problems. A decrease in socioeconomic status was associated with increasing mental health problems. The strength of the correlation varied with age and with different indicators of socioeconomic status, whereas heterogeneous findings were reported for gender and types of mental health problems. The included studies indicated that the theoretical approaches of social causation and classical selection are not mutually exclusive across generations and specific mental health problems; these processes create a cycle of deprivation and mental health problems. The review draws attention to the diversity of measures used to evaluate socioeconomic status, which might have influenced the comparability of international epidemiological studies. Furthermore, the review highlights the need for individual-level early childhood interventions as well as a reduction in socioeconomic inequalities at a societal level to improve mental health in childhood and adolescence.     

Gender differences in health related behaviour: some unanswered questions

To date, no single explanation has accounted for discrepancies between male and female morbidity rates and health care utilization patterns. The sociomedical approach to sex/gender differences in health related behaviour has generated a variety of hypotheses. However, despite extensive study, many unanswered questions remain. The findings of this study fall short of offering conclusive evidence as to the causes of variations in morbidity and health services use between women and men. However, an effort is made to identify the salience of social role and related social status characteristics (e.g. labour force participation) in accounting for variation in health, illness and sick role behaviour. This paper utilizes data from the 1983 Winnipeg Area Study. Findings of this study raise questions about the adequacy of current concepts and measures for studying sex/gender differences in health related behaviour. The study concludes with a critical discussion of conceptual, methodological and theoretical issues which must be considered in our efforts to advance our understanding of why women experience greater longevity, but experience greater morbidity and make more extensive use of health services.     

Engendering the bureaucracy? Challenges and opportunities for mainstreaming gender in Ministries of Health under sector-wide approaches

The increasing ascendancy of 'gender mainstreaming' as the central approach to improving gender equity has largely determined strategies to integrate a gender focus in sector-wide approaches (SWAps). This paper explores the impetus for and process of gender mainstreaming in SWAps in the Ministries of Health in Uganda, Ghana, Malawi and Mozambique, and outlines some achievements and challenges. The shifting and contested relationships between the Ministry of Health, donors and other government ministries (such as Ministries of Finance and Ministries of Women's Affairs/Gender) are important in shaping the opportunities and constraints faced in gender mainstreaming. The refocusing of resource allocation to different sectors has led to changes in the balance of power between the various actors at the national level, with diverse implications for promoting gender equity in health. Some of the achievements to date and ongoing challenges are explored through concrete examples from different countries. These include: the development of structures for mainstreaming, including the dilemmas of the 'focal points' approach and the role of national gender mainstreaming machinery; the need for training and building capacity to identify and address gender issues, which involves engaging with new languages and concepts, and developing new skills; building alliances, consensus and momentum; integrating gender concerns into policy and planning documents; and promoting gender equity in human resources in the health sector. Cross-cutting themes underlying these challenges are the need for gender-specific information and ways to finance mainstreaming strategies. Implications are drawn for ways forward, without losing sight of the challenge of translating discourses of gender mainstreaming, and its central ideal of social transformation, into pragmatic strategies in the bureaucratic environment.     

Gender Mainstreaming in Gesundheitspolitik und -versorgung

By building up an integrated framework of political initiatives, distribution of specific knowledge, consulting, networking and tools for gender mainstreaming, the state of North Rhine Westphalia was successful in integrating a gender perspective into the health system from 2001 to 2006. The process developed in concentric circles--starting with women's rights initiatives, then reaching health politics--and has meanwhile reached health services. Important determinants for success were (1) statewide campaigns and offers of gender-specific consulting that distributed the topic to the city level and health services, (2) the linking of gender mainstreaming and the debate about quality in health services, (3) referring to specific health requirements or health problems of women or men and (4) a precise definition of 'sex' and 'gender'. A difficulty in implementing gender-sensitive approaches in the health system is seen in connecting specific medical or public health knowledge with the more general gender competence. To further promote gender sensibility, gender knowledge and gender-specific approaches to health and illness, an integration of gender mainstreaming tools into strategies and tools of project or quality management is proposed.