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FACULTY OF HEALTH AND SOCIAL SCIENCES
MSc PUBLIC HEALTH
Health and Social Care Inequalities
GENDER HEALTHCARE INEQUALITIES
RICHARD K. FRIMPONG
Gender and health has undeniably been a subject of most debates since the 1970s. Gender equality and equity are increasingly cited as a major policy goal of heath but there is a tremendous confusion about what this mean in theory or practice. Gender is defined as both perceptual and material relationship between men and women (Doyal, 2000). It is not determined biologically, owing to sexual characteristics of either men or women but socially constructed. Gender often governs the processes of productions and reproductions, consumption and distribution and remains a central organizing principle (Massey, 2007). It is often misunderstood as being the promotion of women only. Gender issues emphasises on women and on the relationship between men and women, their access to and control over resources, division of labour, roles, interest and needs. Family planning, productions, household security and numerous aspects of life are affected by gender relations (Brevo-Baumann, 2000).
Gender stereotypes are a conventionally simplified image or standardised conception regarding the typical male and female social roles, both domestically and socially. Thus, gender stereotypes are the notions held concerning traits, characteristics and domains of activies that are deemed appropriate for women and men. For instance women are traditionally deemed to be characteristic of domesticity, submissiveness and piety whereas social behaviour and authority are mostly held by men. Traditionally, Marrying and having children is the female stereotype role (Wikipedia 2012). The welfare of her family is supposed to be the female’s priority before her own; be sympathetic, nurturing, loving, and compassionate; and apportion appropriate time to look beautiful and sexy. Being a financial provider is the stereotypical role of the male. The male is expected to be career -focused, independent, courageous, competitive and assertive; always be the initiator of sex and hold his emotions in check (Judy et al 2005).
A set of behavioural and social norms that are regarded as appropriate for individuals of a specific sex in the context of a particular culture, which differ widely between cultures with the passage of time is termed as Gender roles. Basically, it assumed that gender roles are natural ways of being or behaving, and as such they are not questioned. Children actually receive messages about the female and male roles from the day they are born through a number of ways (Amartya, 2001). A good example of stereotyping gender roles is to consider how colours are coded for babies, boys in blue and girls in pink. The type of toys that is received by boys gives messages about masculinity, for examples, building blocks, cars, and trucks. The kind of toys that young girls receive is indicative of feminine traits such as dress ups and fairies. Messages about gender roles and stereotypes originate from many sources encompassing, teachers, parents, religious leaders, peers, the media, television, magazines, books, sports, radio, fashion, commercial advertisement, internets, fairytales and toys (Southern Australia. Adelaide Health Services, 2008). Apart from some of the social factors elaborated above, culture gives rules about social norms and behaviour thereby being a major contributing factor to gender stereotypes and roles. Through religious, political, legal and economic systems gender roles and stereotype have a history steeped in tradition. For instance it was not until the war triggered a shortage in male workers that women were encouraged to step outside the traditional housewife role work (Simpson, 2005).
In a given culture the distinct roles and behaviours of men and women, dictated by that culture’s gender value and norm, give rise to gender differences. Gender values and norms, however brings about gender inequalities – that is, differences between men and women which systematically empower one group to the detriment of the other. An example of a gender inequality is the fact that throughout the world, women on average have lower cash incomes than men. Gender stereotypes and roles which bring about gender inequality do not only prove to hinder personal and professional growth, stifle individual creativity and expression but tremendously impact on the health of individuals as well.In fact, the gender picture in a given time and place can be one of the major obstacles- sometimes the single most important obstacle -standing between men and women and the achievement of well-being (WHO, 2012).
Their goals must be equitable distribution of health related resources if policies for the promotion of gender equity are to be realisable. This demands a careful identification of the differences and similarity in the health needs of women and men (Doyal, 2000).
Differences in Morbidity and Mortality between Men and Women
There has been an increasing understanding of gender as a key determinant of health, with the growing appreciation of the links between health and socio-economic factors equally as important as the social, economic and ethnic background of any individual. Men and Women are vulnerable to certain illnesses in differing degrees and severity, thus men and women have, to a certain degree, different patterns of ill health (WHO, 2004). Not only is this attributed to their different biology and the reproductive function of women but to the fact that their risk factors and lifestyles differ because their gender roles are different (Sow, 2003).
In all 15 European Union (EU) countries although life expectancy for men and women is increasing, life expectancy for women is greater than that for men in all countries. The average life expectancy at birth in 2003 for women was 81.1years and that for men was 74.8 years. Women suffer a greater burden of unhealthy life years although they live longer than men. Certain diseases have higher incidence and prevalence in women than men. Other diseases including cancer, cardiovascular and mental health affect men and women differently. Depression and stress are more likely to be experience by women which is linked to their experience of discrimination and inequality (Eurostat, 2007).
In Europe about one in four people die of cancer, at some stage of their lives, one in three women are affected by cancer. While the male cancer rates are generally higher than female’s rates, in Denmark, Hungary and Ireland there is a higher overall rate for women (Eurostat, 2007).
Figure1. Deaths from cancer (malignant neoplasm) — standardised death rate, 2004 (per 100 000 inhabitants) (Eurostat, 2007)
The tremendous differences that exist between women and men in the prevalence of particular mental disorders and at different lifecycle stages are often concealed by statistics. Globally, there is a higher prevalence of mental disorders of childhood in boys than in girls, but women are more likely to suffer from poor mental health in later life. It is identified by an eight-population study based in Europe that there continues to be an increase in incidence of dementia and Alzheimer’s disease (AD) with up to 85 years, after which rates do not increase in men but women. The study then concludes that women have a higher risk of AD compared with men. Suicide attempts are higher among women but suicide rates are generally higher amongst men than among women. Compared with men there are lower rates of suicide among women in Italy, Portugal, Latvia and Belgium (Eurostat, 2007).
A concerted effort to overthrow gender health inequality would require a critical look at Gender and its relationship with Work, Health Services Access and Health Related Behaviours (Micheal et al, 2006).
Work and Gender
Women’s mental health is directly affected by their control over labour and earnings. Their contributions have often been underrated although women have been economically productive. Work and gender has a bearing in health outcome people. In this context work is being referred to as any activity that brings in money (paid work) and is carried outside the home. Other activities are performed by women as part of their gender roles but remain unpaid. Some of these activities include production of the next generation, caring for the household, ageing relatives and performing housework. This burden is often manifested or expressed through symptoms of nerves and lack of rest (Burstein, 1994).
Socio-economic difference highlights inequalities between men and women in the labour market. Several legislations including 2007 Gender Equity Duty, 1970 Equal Pay Act, 1975 Sex Discrimination Act, have been put in place to address inequality in men and women in this area. Inequalities continue to exist in the labour market participation representation and pay despite the numerous legislations to address it. As an implication of the differences, women do not possess equitable salaries, status or power as men (Michael and James, 2003).
Based on equitable salary a case was taken to court by a group of female who were catering staff. When the women made a comparism of their pay directly with the pay of their male counterpart in the same job under the same local authority there was a disparity. When the case was referred to the European Court of justice the Women’s employers argue that the cut in the women’s salary was the only way to save money, win future tender and remain competitive. Interestingly, there was no cut in salary for the males who were doing equal jobs with these women. The court ruling went in favour of the women who were afterwards giving equal pay with the men. This issue clearly depicts the gender pay gap between men and women. (European Commission, 2012)
Research has depicted that women are more likely to work for part-timeand or in temporal jobs while mainly concentrated in particular kinds of work like personal service, shop work, care professional, cleaning and administration. In effect, women are more like to be less influential posts, and poorer paid jobs.Womencontinue to incorporate paid work with unpaid work in the home and remain active part of the national workforce. This dual role over the years has led to high levels of stress, exhaustion and depression in women (Dahlgren and Whitehead, 2007).
Poverty and Gender
One of the most significant determinants of health is poverty. The private and the public work of women leave them more vulnerable to poverty (Plat, 2002). Certain sections of the society including single mothers and ethnic minority women are more susceptible to poverty. The so-called choices available to vulnerable women and girls are conditioned and constrain and so the structural pathways highlighted here are directly connected with sexual risk-taking behaviours. For instance transactional sex is significant risk behaviour associated with Human Immuno-deficiency Virus (HIV), which is tied to this pathway (Suneeta et al, 2008). Most girls in developing countries as a result of poverty lack education and information. These girls may unwillingly involve in risky sexual behaviours due lack of information about the risk they face or may be bound in exchange for clothing, food or school fees enter into sexual relationship. Similarly, not only because their current options are limited but also because they cannot envision the potential for a better life, many women may be compelled to engage in high-risk behaviours as a means to manage their economic situation. As a result of economic dependency on male partners combined with social norms that condone male dominance others remain in violent, risky relationships. Thus, by shaping the kinds of alternatives available and by influencing decision-making abilities, these pathways profoundly affect the HIV risk of women and girls.One pathway linking poverty, gender-power inequities and equality, and women’s HIV risk is limited access to HIV prevention–related information and services. It has been revealed through analysis of demographic and health survey data in Cambodia that there is twice the likelihood of women in the wealthiest quintile knowing how to prevent HIV transmission and nearly four times more likely to possess information about HIV testing services than women in the poorest quintile. In Sub-Saharan Africa similar findings have been reported. In Kenya and Thailand a study has found that among client seeking voluntary counselling and testing (VCT) and sexual transmitted infections diagnosis and treatment services, women are underrepresented highlighting gender-related barriers and poverty to women’s use of what are widely recognised as a cornerstone of HIV prevention.Particularly for poor women, in many countries women’s access to VCT is often associated with antenatal care services, which continue to be limited. It is even stigmatizing for women in many context to seek testing and treatment for HIV/STI and in doing so they may risk the stability of their relationships (Pulerwitzet al, 2005). A study has identified that in many countries in Sub-Saharan Africa, economically poor women who are left with little financial support while their partners are away have been found to engage in transactional sex a means of economical survival. These women’s risk of contracting HIV is high (Wardlow, 2007).
Family members who control the largest share of household income and assets have the strongest say in household decision-making. In terms of economic affluence women are at a distinct disadvantage because they earn less than men and tend to own fewer assets. Women’s ability to accumulate capital is restrained by smaller salaries and less control over household income. There is gender bias in inheritance laws and properties as well as other channels of acquiring assets- encompassing state land distribution programmes- which leave children and women at greater risk of poverty. Particularly when a marriage breaks down or the husband dies the consequence of exclusion from owning property or assets can be even more devastating as these poor women are unable to afford for the basic health needs of their children and themselves (UNICEF, 2012).
Healthcare services and Gender
The experience and use of healthcare services differs for men and women as a result of their gender and biological conditions including childbirth, contraception and menopause. Due to gender stereotype men are more reluctant to report ill health and access healthcare services. In a research conducted at the University of California Medical centre, the mean number of visits to their primary care clinic and diagnostic services was significantly higher in women than men. (Klea et al, 2012).
In a comprehensive study that examine the state of women in South Asia and Sub-Saharan Africa, It was identified that women have little influence in health-related matters, although decision on women’s health care are vital to the health and well-being of both women and children. For instance almost 75 percent of women reported that their husbands alone make decision on their access to health-care services in Nigeria, Mali and Burkina Faso. The health and well-being of all family members, particularly children is seriously compromised by this exclusion of women from crucial decisions. (UNICEF, 2012).
Health related behaviour and Gender
It is an established fact that men engage in more risky behaviour while women engage in healthier lifestyle. Compared with women, men mostly do not wear seat belt while driving.More men than women go over the daily recommended alcohol limit alcohol related death e.g. accidents, alcohol related illness more than double those for women In some parts of Africa, certain standard of the society encourage promiscuity on the part of men and discourages women from insisting on the usage of condom. HIV can easily be contracted by the women in such a circumstance (WHO, 2012).
Smoking and drug use is frowned upon in women, while considered an attractive marker of masculinity in many cultures. For this reason mortality rate of lung cancer in a country for men far outstrips the corresponding rate in women (WHO, 2012). Corroborative evidence is depicted by a study of 15 EU countries where among drug users and clients attending drug treatment services, males far outnumber females. For the more illegal drugs and recent or frequent patterns of drug use the number of females in relation to males is generally lower. Moreover, the study identified that Opiate, cocaine and cannabis problems constitute most of the care provided by drug treatment services, for which male clients far outnumber females (Eurostat 2007).
In covering five major topics: coronary artery disease; renal transplantation; human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS); mental illness; and other (mainly invasive) procedures, One hundred and thirty-eight studies were identified. Coronary artery disease was examined by majority (94) of the study. Compared with women it appears that men are more likely to undergo non-invasive investigations. Emphasising on HIV and AIDs patients men are more likely to receive azidothymidine (zidovudine, AZT) than women. The likelihood of men undergoing renal transplantation was higher in men than women. For those undergoing vascular surgery, hip replacement, heart transplantation there are some indication that disparity occur in favour of men. Centrally to the above, women are more likely to undergo cataract surgery and liver transplantation (Raine, 2000).
In spite of much legislation to tackle healthcare inequality between men and women, the gap has not significantly closed. There is the need to revised guidelines in dealing with this social canker.
Tackling Gender Inequality: A Call for Action
One of the most significant determinants of health is poverty and as such there is the need to put in place mechanism and interventions to overwhelm it (Hills, 2005). Conditional Cash Transfer (CCT) is one of such economic interventions. In these programmes cash is transferred conditionally to individuals and households based on certain behaviours, encompassing maintaining children in schools or regular visits to health centres for preventive care. Oportunidades is CCT programmes located in Mexico which provides comparing evidence in favour of the promising effect of CCT intervention on structural pathways, such as access to health services and education. Oportunidades does not only invest nationally in healthcare and educations system to improve services availability but provide cash transfer to poor families conditionally on children’s school attendance and their participation in primary health centre visits. In a randomised control trial which was based on some communities in Mexico it was identified that Oportunidades programme brought about an overall 40% reduction in childhood and adult illness, increase in household income, improvement in child nutrition and improvement in consistency in school attendance. In Columbia and Nicaragua evaluation of similar programs have shown comparable effects (Pronyk et al 2006).
It is also vital to promote the development of capabilities, resources and opportunities that allow individuals to pursue their economic goals. In this approach capabilities are built by means of training in life skills, formal and informal education (Barker, 2006). There is the need to increase health professionals’ knowledge of the impact of gender inequality and norms in disease, disability and death, and to advance the promotion of societal change with a view to eradicating gender as an obstacle to good health (Mercer, 2007). It is vital to heighten knowledge and evidence of how gender inequality impact on particular health services, health problems and successful responses. At the regional and country level that systematically address gender concerns, tools should be developed to promote and expand health sector interventions, policies and programmes. On the other hand the already developed tool must be efficiently disseminated and used (Wilder et al, 2005).
While health services must be appropriate for the special needs of women it must be gender-sensitive. A combined approach considering gender and social change is needed. Programmes and activities to improve the public understanding of gender issues are to be constructed. Some of these activities include the development of advocacy materials and activities, creation of awareness and provision of support to design and promote gender-sensitive health policies and strategies (Pulerwitzet al, 2005).
The fact that gender values and norms are not fixed is a good news. Over time they evolve and vary substantially from one place to another and are subject to change. Thus the consequences of poor health as a result of gender inequalities and differences are not static and can be changed if the above stipulated guidelines are put in place (Buchmann et al, 2008).
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