Gender and Public health

Gender and Public health.

Dr Stephen T. Odonkor

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Key Concepts (1)

The biological differences between women and men, boys and girls, are limited to the differences in their sexual and reproductive organs and functions.

Sex is unchanging and universal. Gender is contextual and variable.

Key Concepts (2)

GENDER has been defined and constructed in different cultures and at different periods of history.

Social norms and expectations of what women and men should be and should do, and about their roles and rights change according to generation, culture and even family

Key Concepts (3)

GENDER

Socially defined roles

Change over time

Influenced by education, income level, religion…

Are different among women and men

SEX

Biological characteristics with which women and men are born

Do not vary

Are not influenced by economic or social factors

Are the same for men and women

Key Concepts (4)

Gender refers to the socially defined roles and responsibilities of men, women and boys and girls. Male and female gender roles are learned from families and communities and vary by culture and generation

Gender equality means the absence of discrimination, on the basis of a person’s sex, in opportunities, in the allocation of resources or benefits or in access to services

Gender equity means fairness and justice in the distribution of benefits and responsibilities between women and men and often requires women-specific projects and programmes to end existing inequities

Global Magnitude

70% of the world’s 7.7 billion people living in poverty are women

Women represent two thirds of the world’s non-literate people

In most developing countries, boys enrolment in school exceeds that of girls

Approximately two thirds of the children of school age who do not or can not go to school are girls

Globally, violence against women causes more deaths and disability among women aged 15 to 44 than do cancer, malaria, traffic accidents or war

Over 4 million girls are at risk each year of female genital mutilation

Women and girls are disproportionately vulnerable to HIV/AIDS, with inequality between men and women fuelling its spread

Many countries continue to discriminate against women in law. Worldwide, women hold only 12% of parliamentary seats

Gender in the context of health

Gender Inequality in relation to health

Lower status/social value in the household

Cultural factors such as lack of female health provider

Being excluded from decision making on health actions and expenditure

Lower literacy rates and reduced access to information

High opportunity costs of women’s labour time –distance, waiting time etc.

Social division of labour (women-informal care provider)

Susceptibility and Treatment to infectious diseases-Malaria & Tb. High

Public health issues like violence, alcoholism, smoking and life style related problems

Gender-Perspective

Gender equality is an issue of development effectiveness, not just a matter of political correctness or kindness to women.

(World Bank 2002)

Gender and Women Health

In many societies, women systematically fail to achieve or fail to use some basic human rights.

Most of the time, women’s health status and problems related to affect:

morbidity

disability

mortality

DISCRIMINATION ALL THROUGH THE LIFE OF WOMEN

CHILDHOOD

Sex selective abortion

Female mutilation

Nutrition problems

Neglect

Cannot benefit from the services

ADOLESENT/ADULT

Unwanted pregnancies, STDs

Sexuel harassment/abuse

Turnpike sex

Smoking and substanve abuse

OLDERS

Increase in morbidity /problems on quality of life

Violence

Social pressure

Increase in morbidity

Female Genital Mutilation (FGM)

An estimated 100 to 140 million girls and women worldwide are currently living with the consequences of FGM.

Each year 2 million girls at risk!

Female genital mutilation (FGM) includes procedures that intentionally alter or injure female genital organs for non-medical reasons.

An estimated 100 to 140 million girls and women worldwide are currently living with the consequences of FGM.

In Africa, about three million girls are at risk for FGM annually.

The procedure has no health benefits for girls and women.

Procedures can cause severe bleeding and problems urinating, and later, potential childbirth complications and newborn deaths.

It is mostly carried out on young girls sometime between infancy and age 15 years.

FGM is internationally recognized as a violation of the human rights of girls and women.

FGM / Problems

Obstetric

Menstruel

Phychological

Urinary

Other problems..

Violence and Women

World scale: Today one of every 3 women are subjected to different forms of violence.

(Heise, Ellsberg, Gottemoeller, 1999).

“…any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field.”

(UN, CEDAW-1994)

Discrimination against women

Sexually Transmitted Disease

Young women know very little information on STDs and because of the fear of being branded as sexual active they hardly try to learn information.

Woman equipping less power as a decision maker has resulted with late diagnosis and treatment.

Sex trade/tourism..

4 million people in sex abuse traffic is estimated in the world.

The revenue / year of organized criminal organizations is 7 billion dollars

500,000 women and children for the sex trade is estimated to infiltrate into European Union countries as at 1995.

WOMEN’S HEALTH

Why do sex differences in mortality and morbidity continue to exist?

How do socioeconomic position, race, and other dimensions of social status interact with gender to produce variations in gender inequity and its health consequences?

How do socially constructed gender roles and differential opportunities shape men’s and women’s lives and turn affect their health?

WOMEN’S HEALTH …

Improved living conditions, better public health and sanitation, better nutrition, and improved medical care and services have benefited both men and women

Mortality rates have fallen and life expectancy has consistently increased for both men and women

Health gains have been greater for women

WOMEN’S HEALTH TRENDS

Current lower mortality for women is a relatively recent occurrence

The present patterns of longer life expectancy for women emerged at the end of the nineteenth century and only in developed countries

Before then, women suffered from excess mortality, attributable to a comparatively harsher life for women and factors such as frequent pregnancies and poor maternal care

WOMEN’S HEALTH TRENDS …

The lives of women in these countries continue to be harsher, due to factors such as:

feudal cultural practices

excessive violence

lack of control by women over their bodies and reproduction

frequent pregnancies

poor nutrition

poor obstetric care (UN, 1995)

WOMEN’S HEALTH – A PARADOX?

Women on average live longer than men, but they also report more illness than men

Women are more likely than men to be hospitalized

The causes for hospitalization are different for males and females

Differences in morbidity and mortality patterns between men and women are evident in other areas

WOMEN’S HEALTH – A PARADOX? …

For example, men are more likely than women to commit suicides, women are twice more likely as men to be depressed and their depression last longer

Women are more likely than men to report conditions such as allergies, headaches etc

While conditions such as arthritis as a cause of activity limitation are frequently reported by women, men report conditions such as heart, back, and limb problems as causing activity limitation

WOMEN’S HEALTH – A PARADOX? …

Women are more likely than men:

To visit health professionals

Make more frequent visits

Use emergency health services

Have recent check-ups

Use more antidepressant drugs than men – consistent with their higher levels of depression

WOMEN’S HEALTH – A PARADOX? …

“Women get sicker, but men die quicker” sums up the morbidity and mortality patterns of men and women in developed countries

How can this paradox be explained?

“Women get sicker, but men die quicker”: Explaining gender differences in health

Artefact explanation

Genetic causation

Social causation

Artefact explanation

Some researchers argue that the differences between men and women are an “artefact,” rather then real

Their main argument is that while women’s health status is not any worse than men’s, women are more likely:

to take notice of their symptoms

are inclined to see a physician

seek treatment

are more willing to respond to health surveys (Miles, 1991)

Biological and genetic explanation

Biological and genetic differences (sex chromosomes and hormones) have also been used to explain morbidity and mortality differences between men and women

Biological and genetic explanation …

Statistics that are often used to show female “superiority” refer to differences in male and female conception, fetal mortality, stillbirths, and infant mortality rates

It is also argued that females, due to their biological and genetic constitution, reproductive anatomy, and physiology, may be endowed with resistance to certain diseases.

Social causation explanation

Social and economic inequalities and socially constructed gender roles have important consequences for men’s and women’s lives and produce variations in health and illness patterns

Social and economic inequalities produce differential opportunities and life chances; social roles and related activities expose men and women to different health risks

The focus here is on the social production of health and illness

Social causation explanation …

Social and economic inequality produce negative health outcomes and poor health status for women

Also it is argued that male socialization and lifestyles expose men to riskier, aggressive, and dangerous behaviour,

For instance, men have higher mortality due to motor vehicle accidents

Men are also more likely to indulge in excessive smoking, drinking, and substance abuse, with negative health consequences

Social causation explanation …

On the other hand, it is pointed out that the often demanding and contradictory social roles of women produce negative health outcomes

For instance, domestic work responsibility and a caring role in the family, combined with the increasing participation of women in the paid work force, may contribute to elevated stress levels among women

Explaining Gender Differences – Theoretical Perspectives

Two theoretical perspectives are advanced to explain gender differences in psychological health:

differential exposure theory

differential vulnerability theory

Both theories attribute gender differences in psychological well-being to the social organization of men’s and women’s lives.

The former emphasizes the extent to which men and women are exposed to particular stressors, whereas the latter focuses on men’s and women’s responses to those stressors (Rieker & Bird, 2000, p, 102).

Differential exposure theory

According to this, women experience hardships and stressors to a greater extent than do men because of their disadvantaged position relative to men in the work force and the inequitable division of work in the household

Married women in particular experience work overload due to work outside home and at home

This overload produce higher psychological distress

Differential vulnerability theory

This theory argues that, the effects of particular stressors differ for men and women for a variety of reasons.

For instance, men and women may attach different meanings and significance to paid work and family roles because of different normative expectations about work and family responsibilities

Differential vulnerability theory …

Sociocultural beliefs and normative expectations may affect men’s and women’s self evaluations as parents and spouses.

Women are more likely than men to experience role conflict and to see their work and family roles as competing rather than integral, and thus they experience more guilt and stress than men

That the consequences of housework and employment differ for men and women and produce different health outcomes

Differential vulnerability theory …

Patterns of health and illness have everything to do with women’s lives, work, employment opportunities, life experience, and social and economic circumstances.

However, it should be noted that social, economic, and other disadvantages do not accrue to all women equally (Macintyre, Hunt, & Sweeting, 1996).

Differential vulnerability theory …

Women are not a homogeneous group, but, rather, are diversified and stratified by class, race, and ethnicity.

The social patterning of health and disease are also differentially experienced by various subgroups.

For instance …

Differential vulnerability theory …

Racial minority women often experience ill health because of unhealthy work environments and harsher working conditions in areas such as farm labour, textiles and sewing, and domestic work

Health status inequalities and the social patterning of disease between diverse groups of women are supported by research findings from other countries

Differential vulnerability theory …

Racial minority women are doubly disadvantaged

Social and economic differentiation and heterogeneity among women produce subgroup differences in health effects and health outcomes.

Health inequality monitoring: with a special focus on low- and middle-income countries

What is monitoring?

Monitoring is repeatedly answering a given study question over time

It helps to determine the impact of policies, programmes and practices, and to indicate whether change is needed

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The study question usually pertains to the measurement of a condition that a policy seeks to impact.

Monitoring has the ability to track policy outcomes over time and provides a means of evaluating the need for policy change.

Once a policy has been changed, subsequent monitoring is necessary to evaluate the outcomes of the new policy, and thus monitoring should be an iterative and cyclical process that operates continuously.

Monitoring alone cannot typically explain the cause of troublesome trends; rather, monitoring may be thought of as a warning system. Monitoring activities can both inform and direct research in a given area.

Applied to the area of health, monitoring picks up trends in health and allows policy-makers to target further research in those areas to determine the root cause of problems.

On-going monitoring may identify subpopulations that are experiencing adverse trends in health.

What is involved in health monitoring?

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Health monitoring is the process of tracking the health of a population and the health system that serves that population. In general, health monitoring is a cyclical process, as shown in this figure:

The process begins by identifying health indicators that are relevant to the study question at hand.

The second step involves obtaining data about those health indicators from one or more data sources.

Data are then analysed to generate information, evidence and knowledge. Depending on the study question, the process of analysing health data can be as simple as creating overall summary statistics about the population’s health, or it can involve more complex statistical analyses.

Following analysis, it is essential to report and disseminate the results so that they can be used to inform policy. The goal should be to ensure that the results of the monitoring process are communicated effectively, and can be used to inform policies, programmes and practice.

Based on monitoring results, changes may be implemented that will impact and improve the health of the population. In order to monitor the effects of these changes, more data must be collected that describe the on-going health of the population; thus, the cycle of monitoring is continuous.

Select relevant health indicators

Obtain data

Analyse data

Report results

Implement changes

Inequity versus inequality

Health inequity: unjust differences in health between persons of different social groups; a normative concept

Health inequality: observable health differences between subgroups within a population; can be measured and monitored

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An explanation of health inequality monitoring begins with the concept of health inequity. Health inequities can be linked to forms of disadvantage such as poverty, discrimination and lack of access to services or goods.

Monitoring health inequalities serves as an indirect means of evaluating health inequity.

Equity-based interventions

Equity-based interventions seek to improve health outcomes in subgroups that are disadvantaged, while improving the overall situation

Targeting expansions in health services specifically towards the most disadvantaged may be more successful and cost effective than using limited resources to create across-the-board increases in services where they are not required by all

For example, nutritional supplementation for children

Interventions that do not have an equity focus may inadvertently exacerbate inequalities, even when national averages indicate overall improvements

For example, media campaigns and workplace smoking bans have shown evidence of increasing inequalities

EXTRA INFORMATION

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What is health inequality monitoring?

Health inequality monitoring describes the differences and changes in health indicators in subgroups of a population

Special considerations:

the need for two different types of intersecting data: health indicator and equity stratifier data

the use of statistical measurements of inequality

the challenges of reporting on different health indicators by different dimensions of inequality

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The process of monitoring social inequalities in health follows the same cycle as any type of health monitoring, although there are some aspects that are unique to health inequality monitoring:

the need for two different types of intersecting data.

The health indicators chosen for use in health inequality monitoring should be reasonably likely to reflect unfair differences between groups that could be corrected by changes to policies, programmes or practices.

While health monitoring only needs to consider data related to health indicators, health inequality monitoring requires an additional intersecting stream of data related to a dimension of inequality (for example, wealth, education, region or sex). This is sometimes referred to as an equity stratifier.

(b) the statistical measurement of inequality, and

(c) the challenge of reporting on different health indicators by different dimensions of inequality in a way that is clear and concise.

Why conduct health inequality monitoring?

To provide information for policies, programmes and practices to reduce health inequity

To evaluate the progress of health interventions

To show a more-complete representation of population health than the national average

Indicates the situation in population subgroups

Disadvantaged subgroups may impede improvements in national figures

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The reduction of inequity is a common goal, from ethical and practical standpoints.

If certain population subgroups continue to be underserved by the health system and suffer a disproportionate burden of morbidity, this endangers the well-being of a society at large and, in some situations, even holds back health progress for the most advantaged.

Ignoring health inequality can present a variety of challenges. If only national averages of health indicators are monitored, they may not provide a complete representation of the changes in the health of a population.

The national average of an indicator could remain constant over time, while certain population subgroups experience improvements in health and other population subgroups see their health deteriorating; it may even be possible to have improving national averages of health indicators while within-country inequality increases.

Disadvantaged population subgroups can also hold back a country’s national figures as outliers that affect national averages.

Donors and the international community look for progress in national health indicators (and increasingly to health inequality explicitly) to make decisions in funding. Addressing health inequalities and improving these figures can thus lead to a better national health system for all, not only those currently disadvantaged.

Equity monitoring is important for health interventions, whether or not targets are equity-specific

Total health inequality versus social inequality in health

Total inequality: the overall distribution of health

Consider only health indicator variables (no equity stratifiers)

Social inequality: health inequalities between social groups

Indicate situations of inequity, where differences between social groups are unjust or unfair

The emphasis of this lecture series

EXTRA INFORMATION

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Those who study health inequality should consider a fundamental decision of whether they wish to measure the overall distribution of health (total inequality) or inequalities between social groups (social inequality).

Measures of total inequality consider only health indicator variables, and involve calculations such as standard deviation and variance.

Measures of social inequalities require at least two intersecting variables related to health indicators and equity stratifiers.

Both are valid and important approaches that contribute to a comprehensive understanding of health inequality in societies.

Making comparisons on a global level

Within-country inequality exists between subgroups within a country, based on disaggregated data and summary measures of inequality

For example, comparing the difference between infant mortality rates among urban and rural subgroups

Cross-country inequality shows variability between countries based on national averages

For example, comparing countries on the basis of national infant mortality rates

Cross-country comparisons of within-country inequality are possible

For example, countries may be compared based on the level of rural–urban inequality in infant mortality rate within each country

EXTRA INFORMATION

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This lecture series and the Handbook on Health Inequality Monitoring focus on within-country inequality.

How can health inequality monitoring lead to implementing change?

Agenda-setting

Health inequality monitoring offers quantitative evidence for policy makers

Analytic data serve as an important basis for identifying where inequalities exist and how they change over time

Other factors to consider: contextual factors, political and popular support, funding, feasibility, timing, cost effectiveness, normative issues, etc.

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Although a particular area may be identified as a priority based on the results of health inequality measures, improvements in the area are only likely to be realized if the environment for change is favourable.

For example, a programme that improves the health of only a small subgroup of a population may not be justified if an alternative programme could impact the health of a greater segment of the population for the same resource cost. These types of decisions may call into question normative issues of what is important and acceptable for a society.

Developing strategies to tackle health inequalities often begins by considering what has already been done in other environments, and whether previous successes are likely to be replicable in a new environment. This step should involve a systematic consideration of evidence to gather information about previous approaches to address a given problem. Experts in the area may be consulted to offer suggestions and recommendations. After learning what has been done by others, decision-makers can begin to consider what might work in their situation. The more thorough the understanding of the situation at hand, the more appropriate a response can be developed.

How can health inequality monitoring lead to implementing change?

Involving key stakeholders

The process of implementing change should involve a diverse group of stakeholders, as appropriate for the health topic

Key stakeholders may include representatives from government, civil society, professional bodies, donor organizations, communities and any other interested group

For example, the World Health Organization’s Commission on Social Determinants of Health is a multisectoral effort to tackle the “causes of causes”

Health inequality issues should be framed as broad problems

Intersectoral approaches help to drive multifaceted solutions and a wide base of support

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Involving stakeholders promotes the success and longevity of policies, programmes and practices.

Consulting with stakeholders helps to ensure a high degree of acceptability and “buy-in” across sectors

Recommendations for promoting equity within the health sector

Recognize that the health sector is part of the problem

Prioritize diseases of the poor

Deploy or improve services where the poor live

Employ appropriate delivery channels

Reduce financial barriers to health care

Set goals and monitor progress through an equity lens

EXTRA INFORMATION

Source: Based on unpublished work by Cesar G Victora, Fernando C Barros, Robert W Scherpbier, Abdelmajid Tibouti and Davidson Gwatkin.

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Recognize that the health sector is part of the problem. Health services do not, on their own, gravitate towards equity. Both public and private services contribute to generating inequalities in health if they are more accessible to the better off.

Prioritize diseases of the poor. When choosing which interventions to implement an essential starting point is to match them closely to the local epidemiological profile of conditions affecting the poor. This requires assessing the burden of disease and allocating resources accordingly.

Deploy or improve services where the poor live. Because health services tend to be more accessible to the urban and better-off populations, there is a natural tendency for new interventions to reach them first. Several recent examples show, however, that this logic can be subverted. Rather than introducing new interventions or programmes initially in the capital and nearby districts, countries can prioritize remote areas where mortality and malnutrition are usually highest.

Employ appropriate delivery channels. The same intervention may be delivered through more than one channel. For example, micronutrients or nutritional counselling may be delivered to mothers and children who spontaneously attend facilities, through outreach sessions in communities, or on a door-to-door basis. Either facility-based or community health workers may be used. Equity considerations are fundamental in choosing the most appropriate delivery channel for reaching the poorest families, who often live far away from the facilities and require community or household delivery strategies.

Reduce financial barriers to health care. Out-of-pocket payments are the principal means of financing health care in most of Africa and Asia. However, this often places extra burden on the sick, who are most likely to be poor, children or elderly. Such user fees would probably not have been instituted had equity considerations been prioritized on the health agenda. Countries adopting a universal health system without any type of user fees, such as Brazil, have lowered levels of inequities in access to first-level health facilities.

Set goals and monitor progress through an equity lens. Progress towards equity depends on the continuous cycle of health inequality monitoring. Each component of the cycle can be strengthened and improved to match the goals of health equity.

How are the social determinants of health related to health inequality monitoring?

Health inequalities tend to stem from social inequalities

Equity stratifiers typically reflect social conditions

Actions to lessen the impact of the social determinants of health promote equity, and thus reduce health inequalities

Three principles of action to achieve health equity:

1. Improve the conditions of daily life (the circumstances in which people are born, grow, live, work and age)

2. Tackle the inequitable distribution of power, money and resources – the structural drivers of the conditions of daily life – at global, national and local levels

3. Raise public awareness about the social determinants of health– measure the problem, evaluate action, expand the knowledge base and develop a workforce that is trained in the social determinants of health

Source: Based on the Final report of the Commission on Social Determinants of Health, World Health Organization, 2008.

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Equity stratifiers (dimensions of inequality) used in health inequality monitoring typically reflect social conditions, such as level of wealth or education, place of residence and gender. A description of social determinants of health encompasses all aspects of living conditions across all life stages, including the health system and wider environment; they are largely shaped by the distribution of resources and power at global, national and local levels.

Monitoring health inequalities reveals differences in how social groups experience health; it does not explain the drivers that cause and perpetuate inequality

To distinguish, the social determinants of health are often pinpointed as the cause of health inequalities.

The movement to garner support to address social determinants of health is inextricably linked to reducing health inequality and achieving health equity. Health inequality monitoring contributes to this end by providing data, direction and evidence.

Extra reading: Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008.

Health inequality monitoring: with a special focus on low- and middle-income countries Full text available online: http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdf