Gender differences in health: a Canadian study of the psychosocial, structural and behavioural determinants of health

Gender-based inequalities in health have been frequently documented. This paper examines the extent to which these inequalities reflect the different social experiences and conditions of men's and women's lives. We address four specific questions. Are there gender differences in mental and physical health? What is the relative importance of the structural, behavioural and psychosocial determinants of health? Are the gender differences in health attributable to the differing structural (socio-economic, age, social support, family arrangement) context in which women and men live, and to their differential exposure to lifestyle (smoking, drinking, exercise, diet) and psychosocial (critical life events, stress, psychological resources) factors? Are gender differences in health also attributable to gender differences in vulnerability to these structural, behavioural and psychosocial determinants of health? Multivariate analyses of Canadian National Population Health Survey data show gender differences in health (measured by self-rated health, functional health, chronic illness and distress). Social structural and psychosocial determinants of health are generally more important for women and behavioural determinants are generally more important for men. Gender differences in exposure to these forces contribute to inequalities in health between men and women, however, statistically significant inequalities remain after controlling for exposure. Gender-based health inequalities are further explained by differential vulnerabilities to social forces between men and women. Our findings suggest the value of models that include a wide range of health and health-determinant variables, and affirm the importance of looking more closely at gender differences in health.     

From causes to solutions - insights from lay knowledge about health inequalities

Background  

This paper reports on a qualitative study of lay knowledge about health inequalities and solutions to address them. Social determinants of health are responsible for a large proportion of health inequalities (unequal levels of health status) and inequities (unfair access to health services and resources) within and between countries. Despite an expanding evidence base supporting action on social determinants, understanding of the impact of these determinants is not widespread and political will appears to be lacking. A small but growing body of research has explored how ordinary people theorise health inequalities and the implications for taking action. The findings are variable, however, in terms of an emphasis on structure versus individual agency and the relationship between being 'at risk' and acceptance of social/structural explanations.     

Contextualising lifestyles: how socially contrasting places in Fife,Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease

Coronary heart disease (CHD) is a significant public health issue showing persistent geographical health inequalities. However, little attention has focussed on lay perspectives of how contrasting social contexts influence lifestyles and health behaviour in relation to CHD. The aim of this qualitative study is to explore lay perspectives of lifestyle and behaviour in socioeconomically contrasting places, with women and men who had survived a heart attack in Fife, Scotland. This study contributes to knowledge on CHD health inequalities and health promotion, particularly cardiac rehabilitation, emphasising the importance of situating experiences and understandings of health, geographically.     

'That's just the cesspool where they dump all the trash': exploring working class men's perceptions and experiences of social capital and health

This article explores issues relating to the concept of social capital which has been become an important explanation for inequalities in health. It is based on an analysis of in-depth interviews with working class men living in two contrasting socio-economic areas--one relatively disadvantaged and one advantaged. It highlights the role of different community contexts in the nature and extent of local social capital. In particular, it demonstrates how de-industrialization and economic change as well as material deprivation and a perceived dis-investment in local communities impacted on the men's levels of social capital. Analysis also shows the ways in which gender mediates the processes through which social capital is developed and accessed as a personal and social resource, and how the norms and values associated with working class masculinities appeared to preclude the men from building supportive health-enhancing relationships with others in their community. The prominence of social capital has focused attention on the subjective dimensions of community life as potential determinants of health. This article has, therefore, sought to contribute to this field by widening our understanding about the relationship between social capital, gender and health.     

Exhausted women,tough men: a qualitative study on gender differences in health,vulnerability and coping with illness in Spain

This study analyses different perceptions by women and men, from different social backgrounds and ages, regarding their health, vulnerability and coping with illness, and describes the main models provided by both sexes to explain determinants for gender inequalities in health. The qualitative study involved in‐depth interviews with women and men resident in Granada (Spain). The women rated their health worse than men, associating it with feelings of exhaustion. However, men tended to overrate their health, hiding their problems behind the ‘tough guy’ stereotype associated with masculinity. Both women and men shared the belief that women are more vulnerable, while men are weaker at coping with illness. The explanatory models offered for this paradox of ‘weak but strong women’ and ‘tough but weak men’ were different for each sex. Men used biological arguments more than women, centred on the female reproductive cycle. Women used more cultural models and identified determinants relating to social stratification, gender roles and power imbalances. In conclusion, gender constructions affect the health perceptions of both women and men at any social level or age. ‘Exhausted’ women and ‘tough’ men should form preferential target groups for intervention to reduce gender inequalities in health.     

Social inequalities in health: are there gender differences?

Some studies suggest that socio-economic status (SES) inequalities in health are smaller in women than men, but the evidence is inconsistent as to whether this applies across various health measures and life stages. The first aim of this paper was to establish whether the magnitude of social inequality in health differs for men and women during early adulthood, specifically in respect to self rated health, limiting long-standing illness, psychological distress, respiratory symptoms, asthma/wheezing, height and obesity; second, to determine whether explanations for socioeconomic inequality in poor self rated health differ for men and women. Analyses are based on longitudinal data from the British 1958 birth cohort study using information from birth to age 33. When gender differences in inequalities were examined using social class, no significant differences emerged across the seven health measures examined at ages 23 and 33. SES inequalities based on education, however, showed greater inequality among men at age 33 for limiting long-standing illness and respiratory symptoms, but greater inequality among women for poor rated health at age 23 and psychological distress at age 33. Hence, gender differences in the magnitude of health inequality were inconsistent across age and health measures. An analysis of the contribution of explanatory factors to social class differences in self-rated health suggested that causes of inequality were similar for men and women. However, some discrepancies emerged, notably in the greater contribution of job insecurity to class differences for men and in the greater contribution of age at first child for women. The magnitude and explanations for gender differences in SES health inequalities are likely to vary according to life stage and health measure.     

Gender differences in the influence of economic,lifestyle, and psychosocial factors on later-life health

BACKGROUND: Gender differences in exposure to social resources play a significant role in influencing gender inequalities in health. A related question--and our focus--asks whether these inequalities are also influenced by gendered vulnerabilities to social forces. Specifically, this paper examines the differential impact of social forces on the health of elderly (65+) men and women. METHODS: Multiple linear regression analysis is used to estimate gender differences in the influence of socioeconomic, lifestyle, and psychosocial factors on both self-rated health and overall functional health using data from the 1994-1995 National Population Health Survey. RESULTS: Key findings include: 1) the relationship between income and health is significant for older women only, whereas the converse holds for education; 2) having an acceptable body weight is positively associated with health for elderly women only; and 3) stress-related factors are stronger determinants of health for older women. INTERPRETATION: Our findings shed light on the processes of healthy aging for men and women, and suggest that interventions to improve the health of elderly Canadians need to be gender-specific.     

The weaker sex? Exploring lay understandings of gender differences in life expectancy: A qualitative study

Despite increasing interest in gender and health, 'lay' perceptions of gender differences in mortality have been neglected. Drawing on semi-structured interview data from 45 men and women in two age cohorts (born in the early 1950s and 1970s) in the UK, we investigated lay explanations for women's longer life expectancy. Our data suggest that respondents were aware of women's increased longevity, but found this difficult to explain. While many accounts were multifactorial, socio-cultural explanations were more common, more detailed and less tentative than biological explanations. Different socio-cultural explanations (i.e. gendered social roles, 'macho' constraints on men and gender differences in health-related behaviours) were linked by the perception that life expectancy would converge as men and women's lives became more similar. Health behaviours such as going to the doctor or drinking alcohol were often located within wider structural contexts. Female respondents were more likely to focus on women's reproductive and caring roles, while male respondents were more likely to focus on how men were disadvantaged by their 'provider' role. We locate these narratives within academic debates about conceptualising gender: e.g. 'gender as structure' versus 'gender as performance', 'gender as difference' versus 'gender as diversity'.     

The Social Context of Women's Health

Health Issue

The discussion of health emphasizes the importance of analyses of social determinants of health. Social determinants permit the targeting of policies towards the social factors that impair or improve health. Two broad questions are considered: (i) what do we know about the social determinants of women's health? (ii) are there gender-related differences in health problems, and how we might explain them?

Key Findings

While 'sex' may be used to denote the biological difference between women and men, it is an imperfect measure of 'gender'. It is argued that a single measure cannot hope to capture the complexity of gender nor the ways in which gender relations change over time and give rise to or exacerbate health problems. The literature on the social determinants of health shows the importance of placing a primary emphasis on addressing the social and economic sources of ill health at national, provincial and community levels.

Data Gaps and Recommendations

Recent studies of gender differences in health point to a lack of data and to the importance of understanding changing gender relations; differences in power and access to resources between women and men, and changing expectations of appropriate gender roles and behaviours. Poverty, social exclusion, unemployment, poor working conditions and unequal gender relations have a profound influence on patterns of health and illness. We suggest some material markers of change that might be used in health surveillance. With a more complete understanding of gender's role in shaping daily lives, these markers could be refined and expanded.

     

Perspectiva de género en epidemiología clínica. Aprendiendo con el caso de las espondiloartritis

ObjectiveTo illustrate some gender challenges and contributions which are more frequent in research and health care through a chronic disease such as spondyloarthritis.MethodUsing two of the main identified gender biases in research and health care (de-contextualization of diseases, especially in women, and problem definition and knowledge production in women's health), a cross-sectional study was used with 96 men and 54 women with spondyloarthritis of the Rheumatology Department of the Alicante University General Hospital, whose sources of information were semi-structured patient interviews and clinical records.ResultsWe show how the gender perspective can contribute to contextualise the differences by sex of functional alterations and other social and health indicators, and highlight inequalities in the socioeconomic repercussions between patients of both sexes. It can contribute towards re-conceptualizing diseases, especially of women, specifying the profile of differential diagnosis according to sex, and provide knowledge about methodological challenges related to diagnostic tests.ConclusionsAchieving scientific and professional excellence in health care is also a gender issue. Analysing from a gender perspective the history of the diseases, how their diagnosis criteria were established and the normality and abnormality cut-off points, especially identified diseases of men, such as spondyloarthritis, is a priority to re-conceptualize medicine; as well as providing information on how the gender norms and values of the context interact with the lives of those who suffer these diseases.     

Why build a health promotion evidence base about gender?

Gender has long been recognized as an important determinantof health service usage, but gender is increasingly importantin understanding how women and men experience and respond tohealth promotion programs and interventions and their outcomes.Gender frameworks are vital for understanding not just the differingeffects of the determinants of health on either women or men(Doyal, 1995; Krieger, 2000), but also how health programs shouldrespond in order to improve health outcomes for either womenor men. Much needs to be done to improve the evidence base inhealth promotion with respect to gender. Gender, as a determinant of health, refers to inter-relateddimensions of biological difference, psychological differenceand social experience. Biological     

Sex inequalities in physical and mental functioning of British, Finnish, and Japanese civil servants: role of job demand, control and work hours

In general, women report more physical and mental symptoms than men. International comparisons of countries with different welfare state regimes may provide further understanding of the social determinants of sex inequalities in health. This study aims to evaluate (1) whether there are sex inequalities in health functioning as measured by the Short Form 36 (SF-36), and (2) whether work characteristics contribute to the sex inequalities in health among employees from Britain, Finland, and Japan, representing liberal, social democratic, and conservative welfare state regimes, respectively. The participants were 7340 (5122 men and 2218 women) British employees, 2297 (1638 men and 659 women) Japanese employees, and 8164 (1649 men and 6515 women) Finnish employees. All the participants were civil servants aged 40-60 years. We found that more women than men tended to have disadvantaged work characteristics (i.e. low employment grade, low job control, high job demands, and long work hours) but such sex differences were relatively smaller among employees from Finland, where more gender equal policies exist than Britain and Japan. The age-adjusted odds ratio (OR) of women for poor physical functioning was the largest for British women (OR = 2.08), followed by for Japanese women (OR = 1.72), and then for Finnish women (OR = 1.51). The age-adjusted OR of women for poor mental functioning was the largest for Japanese women (OR = 1.91), followed by for British women (OR = 1.45), and then for Finnish women (OR = 1.07). Thus, sex differences in physical and mental health was the smallest in the Finnish population. The larger the sex differences in work characteristics, the larger the sex differences in health and the reduction in the sex differences in health after adjustment for work characteristics. These results suggest that egalitarian and gender equal policies may contribute to smaller sex differences in health, through smaller differences in disadvantaged work characteristics between men and women.     

‘They can’t report abuse,they can’t move out. They are at the mercy of these men’: exploring connections between intimate partner violence,gender and HIV in South African clinical settings

This qualitative study captured South African female health provider perspectives of intimate partner violence in female patients, gender norms and consequences for patients’ health. Findings indicated female patients’ health behaviours were predicated on sociocultural norms of submission to men’s authority and economic dependence on their partners. Respondents described how men’s preferences and health decision-making in clinics affected their patients’ health. Adverse gender norms and gender inequalities affected women’s opportunities to be healthy, contributing to HIV risk and undermining effective HIV management in this context. Some providers, seeking to deliver a standard of quality healthcare to their female patients, demonstrated a willingness to challenge patriarchal gender relations. Findings enhance understanding of how socially-sanctioned gender norms, intimate partner violence and HIV are synergistic, also reaffirming the need for integrated HIV-intimate partner violence responses in multi-sector national strategic plans. Health providers’ intimate knowledge of the lived experiences of female patients with intimate partner violence and/or HIV deepens understanding of how adverse gender norms generate health risks for women in ways that may inform policy and clinical practice in South Africa and other high-HIV prevalence settings.     

Theorising Inequalities in Health: The Place of Lay Knowledge

This paper contributes to the development of theory and research on inequalities in health. Our central premise is that these are currently limited because they fail adequately to address the relationship between agency and structure, and that lay knowledge in the form of narrative has a significant contribution to make to this endeavour. The paper is divided into three sections. In the first section we briefly review the existing, largely quantitative research on inequalities in health. We then move on to consider some of the most significant critiques of this body of work highlighting three issues: the pursuit of overly simple unidimensional explanations within ‘risk factor’ epidemiology and the (probably inevitable) inability of this research tradition to encompass the full complexity of social processes; the failure to consider the social context of individual behaviour and, in particular, the possibility for, and determinants of, creative human agency; and, thirdly, the need for ‘place’ and ‘time’ (both historical and biographical) to be given greater theoretical prominence. In the final section of the paper the potential theoretical significance of ‘place’ and ‘lay knowledge’, and the relationship between these concepts, in inequalities research is explored. Here we suggest three developments as a necessary condition for a more adequate theoretical framework in this field. We consider first the need for the conceptualisation and measurement of ‘place’ within a historical context, as the location in which macro social structures impact on people’s lives. Second, we argue for a re-conceptualisation of lay knowledge about everyday life in general and the nature and causes of health and illness in particular, as narratives which have embedded within them explanations for what people do and why – and which, in turn, shape social action. Finally, we suggest that this narrative knowledge is also the medium through which people locate themselves within the places they inhabit and determine how to act within and upon them. Lay knowledge therefore offers a vitally important but neglected perspective on the relationship between social context and the experience of health and illness at the individual and population level.     

Tobacco control and the inequitable socio-economic distribution of smoking: smokers’ discourses and implications for tobacco control

Warning: this article contains strong language.

This paper focuses on the ways in which social context structures smokers’ views of, and reactions to, tobacco control. This exploratory study examined the interactions between tobacco control and smokers’ social contexts and how this may be contributing to inequalities in smoking. We found in our sample that higher socio-economic status (SES) smokers are more likely to positively respond and adapt to tobacco control messages and policies, viewing them for their future health betterment. Lower SES smokers in our study, on the other hand, are in conflict with tobacco control and feel intransigent with regard to the effects that tobacco control is having on their smoking. A better understanding of how social context structures people's perceptions of tobacco control may help us to understand why social inequalities in smoking are deepening, and potentially what can be done better in tobacco control to decrease them.     

Can We Capture the Intersections? Older Black Women,Education, and Health

BackgroundRace/ethnicity, gender, and socioeconomic status are the three most prominent factors to predict health outcomes. Despite the fact that persistent health inequalities are found between groups, we know little about how the interrelatedness of these social positions influences the health of older adults.PurposeIn this study, we apply a feminist intersectional approach to the study of health inequalities, treating social variables as multiplicative rather than additive to capture the mutually constitutive dimensions of race/ethnicity, gender, and education.MethodsThis paper makes use of data from the National Social Life, Health and Aging Project, a nationally representative sample of 3,005 community-dwelling U.S. adults aged 57 to 85 years old, to explore intersections of race, gender, and education. We use a combination of stratified analysis with an interaction term to test multiplicative effects.ResultsFirst, our findings confirm that Black women with less than a high school education have the poorest self-rated health. Second, at the bivariate level, we find highly educated White men are not the converse of lower educated Black women. Third, at the multivariate level, we find being Black and female has an effect on health beyond those already accounted for by race and gender.ConclusionThis research demonstrates the explanatory power of an intersectionality approach to deepen understanding of the overlapping, simultaneous production of health inequalities by race, class, and gender.     

Understanding gendered influences on women's reproductive health in Pakistan: Moving beyond the autonomy paradigm

Recent research and policy discourse commonly view the limited autonomy of women in developing countries as a key barrier to improvements in their reproductive health. Rarely, however, is the notion of women's autonomy interrogated for its conceptual adequacy or usefulness for understanding the determinants of women's reproductive health, effective policy formulation or program design. Using ethnographic data from 2001, including social mapping exercises, observation of daily life, interviews, case studies and focus group discussions, this paper draws attention to the incongruities between the concept of women's autonomy and the gendered social, cultural, economic and political realities of women's lives in rural Punjab, Pakistan. These inadequacies include: the concept's undue emphasis on women's independent, autonomous action; a lack of attention to men and masculinities; a disregard for the multi-sited constitution of gender relations and gender inequality; an erroneous assumption that uptake of reproductive health services is an indicator of autonomy; and a failure to explore the interplay of other axes of disadvantage such as caste, class or socio-economic position. This paper calls for alternative, more nuanced, theoretical approaches for conceptualizing gender inequalities in order to enhance our understanding of women's reproductive wellbeing in Pakistan. The extent to which our arguments may be relevant to the wider South Asian context, and women's lives in other parts of the world, is also discussed.     

Gender-specific responses to social determinants associated with self-perceived health in Taiwan: a multilevel approach

There are well-documented gender differences in health. However, few studies have considered that the associations of personal and household characteristics with perceived health may vary between men and women because of their different socialized gender roles. This study investigates gender differences in health and addresses gender-specific responses to individual- and household-level determinants of health. We analyze the data of the 2001 Social Development Survey on Health and Safety, which consists of a representative sample of all registered households in Taiwan. Our findings give limited support to the hypothesis that women and men are differently associated with social determinants of health. We observe a significant gender gap in self-perceived health even after controlling for various health determinants. Notwithstanding, men and women are similar in many important aspects in relation to social determinants of health. Gender-specific responses are found only in the impacts of employment status, stressful life events, own disability, and number of family members with a disability. Men report having poorer health than women when being disabled and facing stressful events. Women's perceived health is at a higher risk when family members require short-term, intensive care. Further consideration of the observed, gender-specific responses to health determinants shed insight on the possible social and cultural relevance behind gender differences in self-perceived health.     

Determinantes sociales de la salud de distintos niveles por género: educación y hogar en España

Objective

To explore from a gender perspective the association with subjective health of the interaction between education and household arrangements within the framework of social determinants of health placed at the micro and mezzo levels.