Gender, health inequalities and welfare state regimes: a cross-national study of 13 European countries

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1 Researh report Additional tables are published online only at jeh.bmj.om/ontent/vol63/ issue1 1 Department of Geography, University of Durham, UK; 2 Division of Publi Health, University of Liverpool, UK; 3 Department of Publi Health, Erasmus MC, The Netherlands Correspondene to: Dr C Bambra, Department of Geography, Wolfson Researh Institute, Queen s Campus, Durham University, Stokton on Tees TS17 6BH, UK; lare. bambra@durham.a.uk Aepted 31 July 2008 Published Online First 3 September 2008 Gender, health inequalities and welfare state regimes: a ross-national study of 13 European ountries C Bambra, 1 D Pope, 2 V Swami, 2 D Stanistreet, 2 A Roskam, 3 A Kunst, 3 A Sott-Samuel 2 ABSTRACT Bakground: This study is the first to examine the relationship between gender and self-assessed health (SAH), and the extent to whih this varies by soioeonomi position in different European welfare state regimes (Liberal, Corporatist, Soial Demorati, Southern). Methods: The EUROTHINE harmonised data set (based on representative ross-setional national health surveys onduted between 1998 and 2004) was used to analyse SAH differenes by gender and soioeonomi position (eduational rank) in different welfare states. The sample sizes ranged from 7124 (Germany) to (Italy) and onerned the adult population (aged >16 years). Results: Logisti regression analysis (adjusting for age) identified signifiant gender differenes in SAH in nine European welfare states. In the UK (OR 0.88; 95% CI 0.78 to 0.99) and Finland (OR 0.85; 95% CI 0.77 to 0.95), men were signifiantly more likely to report bad or very bad health. In Denmark, Sweden, Norway, Holland, Italy, Spain and Portugal, a signifiantly higher proportion of women than men reported that their health was bad or very bad. The inreased risk of poor SAH experiened by women from these ountries ranged from a 23% inrease in Denmark (OR 1.23; 95% CI 1.08 to 1.39) to more than a twofold inrease in Portugal (OR 2.01; 95% CI 1.87 to 2.15). For some ountries (Italy, Portugal, Sweden), women s relatively worse SAH tended to be most prominent in the group with the highest level of eduation. Disussion: Women in the Soial Demorati and Southern welfare states were more likely to report worse SAH than men. In the Corporatist ountries, there were no gender differenes in SAH. There was no onsistent welfare state regime patterning for gender differenes in SAH by soioeonomi position. These findings onstitute a hallenge to regime theory and omparative soial epidemiology to engage more with issues of gender. Gender differenes in health are well doumented in terms of both mortality and morbidity. 1 However, the extent to whih gender differenes in health vary by soioeonomi position is less well doumented. 2 Furthermore, although welfare state arrangements and soial poliies are inreasingly being aknowledged as important determinants of health and of inequalities in health, 3 8 there is little researh into how gender differenes in health vary by welfare state; speifially, there has been little gendered analysis with a fous on the impliations for women As part of the EUROTHINE projet, this study foused on gender and health inequality in 13 European welfare states, representing four welfare state regimes: Finland, Sweden, Norway, Denmark, Holland, Ireland, England, Belgium, Germany, Frane, Italy, Portugal and Spain. GENDER INEQUALITIES IN HEALTH Over several deades, researh on gender differenes in mortality and morbidity has highlighted an important paradox. On the one hand, a wealth of evidene suggests that, in soioeonomially developed nations, men have shorter life expetanies than women This gender differene is largest for violent auses of death and from early adulthood until middle age, but remains fairly stable throughout the life ourse On the other hand, women in ontrast to their lower mortality atually report higher morbidity aording to self-assessed indiators, inluding limiting long-term illness and self-assessed health (SAH). Although some researhers have questioned the existene of this gender differene, 24 most ontemporary work suggests that the paradox is real, albeit smaller than previously thought Traditionally, this paradox has been explained as the result of gender differenes in the distribution of biologial, behavioural or psyhologial traits. 28 However, there remains some debate as to the best explanation for the paradox in atual mortality and SAH, and it has been suggested that gender differenes in mortality may differ between different soioeonomi groups or aross ountries. 30 It is therefore possible that gender differenes in SAH may also vary by ountry or, indeed, welfare state type. In fat, evidene suggests that genderequitable soial organisation redues gender inequalities in both SAH 31 and life expetany. 32 WELFARE STATES, HEALTH AND HEALTH INEQUALITIES Welfare states are important determinants of health and health inequalities as they mediate the extent, and impat, of soioeonomi position on health. 3 8 Welfare state provision varies extensively aross the Western world but typologies have been put forward to ategorise it into three, four or even five distintive types or welfare state regimes. 9 In terms of Europe, although a partiular ountry s lassifiation is often ontested (eg, UK, Holland, Italy) and the quality of typologies questioned, 9 a onsensus is gradually emerging that there are four ore welfare state regime types (see Ferrera 33 and Bambra 34 ): Soial Demorati (Denmark, Norway, Sweden and, to a lesser extent, Finland and 38 J Epidemiol Community Health 2009;63: doi: /jeh J Epidemiol Community Health: first published as /jeh on 3 September Downloaded from on 19 June 2018 by guest. 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2 Holland); Corporatist (Belgium, Frane, Germany); Liberal (England, Ireland); and Southern (Italy, Spain, Portugal). Studies that have examined how health varies by welfare state regime have invariably all onluded that population health is enhaned, and (absolute though not relative) 35 inequalities in health redued, by the omparatively generous and universal welfare provision of the Soial Demorati ountries The mainstream omparative welfare state regime literature has only reently begun to seriously onsider that the inome redistribution, deommodifiation and other soial effets of welfare state arrangements may vary by gender and that separate gendered typologies of welfare states may therefore be required. 36 However, this debate has not yet filtered through to publi health researhers and, to date, no studies have examined how gender differenes in health vary by welfare state regime. 9 Similarly, ross-national studies of inequalities in health have only reently begun to examine gender differenes by welfare state type. It is worth noting that some studies have onsidered soioeonomi status as the basis of health inequalities between women and men, but this literature has tended to neglet the role of welfare state typologies. This body of work suggests that soioeonomi differenes in SAH are found for both women and men, although some authors have suggested that individual soioeonomi differenes are less marked for women s health. Other studies have reported signifiant interations between women s health status and proxies of soioeonomi status, suh as employment, marital status and housing tenure However, with few exeptions, 51 these studies have not tended to onsider how soioeonomi position may be differentially related to the reported health of women and men in different ountries or welfare state regimes. In this ontext, this study is the first to examine the relationship between gender and SAH and the extent to whih this varies by soioeonomi position in different European welfare states and to what extent this an be explained by welfare state regime theory. METHODS This study was onduted as part of the European Unionfunded Takling Health Inequalities in Europe (EUROTHINE) projet. The EUROTHINE projet ollated and harmonised data from various representative national health surveys of adults (aged >16), arried out between 1998 and Sample sizes ranged from 7124 (Germany) to (Italy). Information on the individual ountry data soures are presented in table 1. Further information is available from the EUROTHINE website ( SAH was measured using a five-point Likert-type sale ranging from very good health to very bad health. To maximise the effiieny of the analysis SAH was dihotomised to ompare bad and very bad health with average to very good health. Eduational status was standardised aross ountries using the International Standard Classifiation of Eduation (ISCED), a four-point ranked sale with the lowest rank indiating the most eduated (university/higher eduation) and highest rank the least eduated (primary eduation and below). For the purpose of the urrent analysis, eduational rank was used as a proxy for soioeonomi position. Two desriptive analyses were onduted. The first explored the relationship between SAH and gender in eah ountry, adjusting for age in years. The seond stratified the analysis aording to the four eduational ranks. Logisti regression analysis was used for both analyses to obtain odds ratios Researh report summarising the relationship between SAH and gender (age adjusted). Men were the referene group for gender and for the outome of SAH average to very good health was the referene. RESULTS The proportion of individuals indiating bad and very bad health varied between partiipating ountries (see on line tables). For the majority the ourrene of poor health was less than 10%; however, lear exeptions were Germany (17.5%) and Portugal (25.9%). For all the ountries, exept Ireland, there was a signifiant relationship between gender and self-reported poor health (p,0.05). England and Finland were the only ountries to have a higher proportion of men reporting bad and very bad health relative to women. The remaining ountries had a higher prevalene of self-reported poor health in women (see online tables). For all ountries eduational level was strongly related to self-reported poor health, with the least eduated group reporting the highest levels of bad and very bad health. Statistially signifiant differenes in SAH by gender were observed for nine of the 13 European ountries (table 2). In Denmark, Sweden, Norway, Holland, Italy, Spain and Portugal, a signifiantly higher proportion of women reported that their health was bad or very bad ompared with men. The inreased risk of poor SAH experiened by women from these ountries ranged from a 23% inrease in Denmark (odds ratio (OR) 1.23; 95% onfidene interval (CI) 1.08 to 1.39) to more than a twofold inrease in Portugal (OR 2.01; 95% CI 1.87 to 2.15). In the UK (OR 0.88; 95% CI 0.78 to 0.99) and Finland (OR 0.85; 0.77 to 0.95) men were signifiantly more likely to report bad or very bad health. There were no signifiant gender differenes in SAH for Belgium, Frane, Germany and Ireland. The relationship between gender and SAH, stratified by eduational rank, appeared to vary between the ountries (figure 1). For Italy, Portugal and Sweden, the inreased risk of poor SAH in women appeared to be greatest in the most eduated group. For Denmark, Spain, Holland and Norway there was no lear relationship between the inreased risk of poor SAH in women and eduational level. The redued risk of poor SAH in women from England was only statistially signifiant (borderline) for the least eduated (table 2: OR 0.84; 95% CI 0.71 to 0.99), whereas for women from Finland the only signifiant assoiation between gender and SAH was among the most eduated (see online tables: OR 0.86; 95% CI 0.78 to 0.95). DISCUSSION The results suggest that the relationship between gender and SAH, and the extent to whih it varies by soioeonomi position, does in fat differ aross European welfare states. In the majority of ases, women reported worse health than men, and in some ountries (Italy, Sweden, Portugal), these differenes were most pronouned among the most highly eduated. Some of the results (eg, for Portugal and Italy) an be explained by drawing on welfare state regime theory Other ountries findings (eg, UK or Finland) are more hallenging to welfare state regime theory. Furthermore, the finding that gender differenes in SAH are most prominent in the most eduated groups in some ountries requires further disussion. Confirming welfare state regime theory The fourfold typology of welfare states is very evident in our results: women who are moderately more likely to report bad J Epidemiol Community Health 2009;63: doi: /jeh J Epidemiol Community Health: first published as /jeh on 3 September Downloaded from on 19 June 2018 by guest. Proteted by opyright.

3 Researh report Table 1 Information on data soures for eah ountry (presented by welfare state regime)* Country Data soure Year(s) of survey Soial Demorati Denmark Danish Health and Morbidity Survey 2000 Finland Finbalt Health Monitor 1994, 1998, 2000, 2002, 2004 Holland General soial survey Norway Norwegian Survey of Living Conditions 2002 Sweden Swedish Survey of Living Conditions Corporatist Belgium Health Interview Survey Frane Frenh Health, Health Care and Insurane 2004 Survey Germany German National Health Examination and 1998 Interview Survey Liberal England Health Survey for England 2001 Ireland Living in Ireland Panel Survey Southern Italy Health onditions and use of health servies Portugal National Health Survey 2001 Spain National Health Survey 2001 *Soure: or very bad SAH are those in the Soial Demorati ountries of Denmark, Holland, Norway and Sweden; women in the Southern regime ountries of Portugal and Italy (and to a lesser extent Spain) are highly likely to report worse SAH; whereas those ountries in whih there appear to be no gender differenes in SAH are the Corporatist ountries of Belgium, Frane and Germany. The only exeptions to this are Finland, England and Ireland. In welfare state regime theory, Finland is something of a hybrid ase, with some typologies plaing it in the Soial Demorati regime 33 while others plae it in the Corporatist 53 welfare state regime. This is perhaps a refletion of the shorter history of the welfare state in Finland (whih was not developed until the 1970s) ompared with the other Nordi welfare states. England and Ireland are almost always plaed together in the Liberal regime type. Welfare state regime theory is therefore able to provide some insight into how the ountries analysed have grouped in terms of gender differenes in SAH. However, although the high levels of bad or very bad SAH among women in the Southern regime ountries reinfores researh into gender and welfare states regimes, whih has long highlighted the lak of support for women and their low eonomi and politial partiipation in these ountries, 58 the results for the other regime types is less easy to explain through referene to this literature. Challenging welfare state regime theory Researh into population health differenes aross welfare states has tended to find that health is better in the Soial Demorati ountries. Furthermore, these welfare states are widely seen as the most progressive in terms of gender equality. So the expetation would therefore be that gender differenes in SAH would be omparatively smaller in the Soial Demorati ountries. However, this was not the ase in our study. One possible explanation is that the mehanisms at play in terms of gender and health annot be overome by the traditional Soial Demorati welfare interventions of inome redistribution and extensive publi servie provision alone. 8 Indeed, some feminist ritiques have suggested that suh poliies have atually transferred women s eonomi dependeny Table 2 ORs and 95% CIs for the assoiation of gender with the risk of reporting bad or very bad self-assessed health ompared with regular, good or very good selfassessed health* Total OR (95% CI) Soial Demorati Denmark 1.23 (1.08 to 1.39) Finland 0.85 (0.77 to 0.95) Holland 1.44 (1.29 to 1.60) Norway 1.51 (1.23 to 1.87) Sweden 1.23 (1.06 to 1.44) Corporatist Belgium 1.09 (0.94 to 1.27) Frane 1.15 (0.95 to 1.38) Germany 1.13 (1.00 to 1.29) Liberal England 0.88 (0.78 to 0.99) Ireland 0.93 (0.77 to 1.12) Southern Italy 1.33 (1.27 to 1.39) Portugal 2.01 (1.87 to 2.15) Spain 1.37 (1.23 to 1.53) *ORs are age adjusted; men are the referene ategory for all omparisons. from the family to the state from private to publi patriarhy Interlinked with this is the burden of the dual roles experiened by women in Soial Demorati states. A high proportion of women work and, although publi poliy is progressive in terms of hildare and paternity leave, women are still responsible for the majority of domesti work and family are Similarly, the suggestion has been made that the dualearner model leads to indiret disrimination against women as all women, even those very voationally foused, are treated as potential mothers leading to women being put onto parallel mommy areer traks. 64 This may partly explain the high sexual segregation at work, and the gender pay gap in the Sandinavian ountries that exists between men and women as opposed to between mothers and others as is the ase in other Western ountries. 64 Perhaps another fator behind the results is the higher proportion of lone mothers in Soial Demorati states 65 who experiene worse health than ouple mothers. 65 Of ourse, the English and Finnish results suggest that these relationships may not be onsistent aross all ountries with high labour market partiipation by women. Further analysis using other measures of health (suh as mortality data) would help to explore the onsisteny of this finding. No signifiant gender differenes in SAH were found in the Corporatist ountries (Belgium, Frane and Germany), or in Ireland. The Corporatist welfare states are often onsidered to offer a ontraditory set of poliies and provisions in relation to women and the family On the one hand, they provide some of the best provisions for women (eg, well-ompensated and extensive maternity leave) whereas, on the other hand, they have muh lower levels of labour market partiipation by women. The lak of gender differene in SAH ould therefore reflet the fat that fewer women in the Corporatist ountries experiene dual roles. Similarly, there are lower levels of lone motherhood in the Corporatist ountries (and Ireland). Conversely, the ases of Italy, Portugal and, albeit to a lesser extent, Spain aution that restritive traditional gender roles for women an have an extremely adverse effet on gender differenes in health. 40 J Epidemiol Community Health 2009;63: doi: /jeh J Epidemiol Community Health: first published as /jeh on 3 September Downloaded from on 19 June 2018 by guest. Proteted by opyright.

4 Figure 1 ORs and 95% CIs for the assoiation of gender (stratified by eduational rank) with the risk of reporting bad or very bad self-assessed health ompared with regular, good or very good self-assessed health. ORs are age adjusted; men are the referene ategory for all omparisons. Welfare state regimes and gender inequality in health In terms of gender differenes in SAH stratified by eduational rank, it is of note that there appears to be a stronger relationship in the most eduated group for a number of European ountries. For example, in the Southern regime ountries of Italy and Portugal (but not Spain), the inreased risk of poor SAH in women appeared to be greatest among the most highly eduated. This may be a result of tensions between the traditional roles of women as wife and mother and the new pressures for women, partiularly the most eduated, to work. Indeed, there are large eduation-related differenes in labour fore partiipation among Southern European women; partiipation is generally higher among women of higher eduation, whereas lower eduated women generally assume more traditional role patterns 66 and onform to the Mediterranean male breadwinner model. 68 Traditional ultural norms and orresponding state provision (minimal or no hildare support, et, in part due to the later development of the welfare state) in the Southern regime ountries therefore do not support these dual roles. 68 The higher prevalene of smoking among more eduated women in the Southern regime ountries may also be a ontributory fator. 69 This was also the ase in Soial Demorati Sweden. However, in Finland, women in the highest group reported better SAH than men. In the other Soial Demorati ountries (Denmark, Holland and Norway), there was no lear relationship between the inreased risk of poor SAH in women and eduational rank. In England, the redued risk of poor SAH reported by women was only among the least eduated. Although Researh report it is possible to explain the higher rates of poor SAH among more eduated women in terms of the pressures of these women s dual roles, the results are inonsistent and are therefore diffiult to explain in a oherent way without further researh. Poliy impliations Our results suggest that the nature of gender differenes in health vary by ountry and to some extent by welfare state type. Therefore, ahieving gender equity in health will require different poliy responses in eah European welfare state. The results for the Soial Demorati welfare states suggest that welfarist poliies annot adequately overome genderbased inequities in health without aompanying hanges at the ultural and soietal levels. To start, we suggest implementing poliies whih target gender soialisation and traditional gender roles. A good example of suh poliies would be the reommendations of the Swedish Eduation Ministry s Delegation for Gender Equality in Preshool. The results for Italy and Portugal reinfore this suggestion, as the tension between traditional and modern roles experiened by women in these ountries is detrimental to SAH. The lak of gender differenes in SAH in the Corporatist ountries and our suggestion that this may be due to the existene of more dual ouples and fewer dual roles for women implies that publi poliy interventions need to ompensate more adequately for the lak of support experiened by lone mothers and by working women in general. Current state provision, even in the Soial Demorati ountries, has not yet adequately J Epidemiol Community Health 2009;63: doi: /jeh J Epidemiol Community Health: first published as /jeh on 3 September Downloaded from on 19 June 2018 by guest. Proteted by opyright.

5 Researh report ompensated for the detrimental health effets of lone parenthood, 65 and the dual earner model may have unintended onsequenes for women suh as gender segregation at work. 64 This may require more extensive soialised hildare, as well as enhaned flexibility around working hours. There are some indiations in our analysis that, in a variety of ountries, the inreased risk of poor SAH in women appeared to be greatest in the highest eduational rank. This may also neessitate poliy interventions to support women with dual roles. Strengths and limitations The EUROTHINE projet provides the unique opportunity to ompare gender differenes in health aross Europe using large, representative ross-setions of the adult population. Comparisons are made easier by the use of standardised lassifiations of important variables (eg, eduational rank). However, national-level data annot be used to make preditions at the level of the individual. One limitation is the use of eduational rank as a proxy for soioeonomi position. This relationship is unlikely to be uniform aross all European ountries. Furthermore, and of partiular importane for this study, women s eduational bakground may not be a very aurate indiator of their soioeonomi position. Indeed, researh into soioeonomi inequalities in health among men and women have highlighted the sensitivity of the hoie of indiator of soioeonomi position. 2 A further issue onerns the possibility that within welfare regimes there ould be diret, differential effets of different eduational systems on gender inequalities in health. Although SAH orrelates well with other indiators of morbidity 71 and is onsidered to be a good indiator to ompare health aross ountries, 72 it should be aknowledged that there may well be differenes in reporting aross ountries, ultures, ethniity, soioeonomi groups and, of ourse, by gender. 73 It is also likely that there are variations in SAH between age groups, and different welfare state regimes will have poliies that at differentially at various stages in the life yle as well as by gender. For example, gender differenes in health also differ by oupational harateristis 74 and younger women may be more likely to live with their parents; oupation ould therefore be an important onfounding fator. 75 Similarly, the institutionalisation of older people may vary by gender in different ountries. Future researh would benefit from examining SAH between different age groups (as well as the interation between gender and other forms of soial stratifiation suh as ethniity) to asertain whether the patterns reported here vary by age as well as by welfare state regime and level of eduation. Another possible limitation is our hoie of welfare state regime typology. There are a multitude of ompeting welfare state regime typologies 9 and, although there is no ategorisation whih has been generally aepted as the standard typology, the fourfold typology of Ferrera 33 used in this paper has been highlighted as one of the most empirially aurate, 34 at least in terms of how soial benefits are granted and organised. However, if the typologies of other authors were used the results may have been different. For example, if the politial traditions typology suggested by Navarro et al 7 were utilised, the Christian Demorati group of ountries (similar to Bismarkian regime) would inlude those with smaller gender inequalities (Germany, Frane) as well as those with higher gender inequalities (Italy). This needs to be taken into borne in mind when onsidering our results. CONCLUSION Current welfare regime theory learly offers some explanatory insight into gender differenes in health. However, until more work on the gendered nature of welfare states has been undertaken and is available for use by publi health researhers, regime theory may not be as useful in examining gender and health as it has been in terms of overall population health. 3 7 One obvious route to pursue relates to relationships between gender inequalities in health and gendered publi poliy indiators and typologies, suh as the Gender Equity Index. 76 What is already known on this subjet International researh has shown that different types of welfare states (welfare state regimes) are important determinants of health and health inequalities as they mediate the extent, and impat, of soioeonomi position on health. To date, however, no studies have examined how gender differenes in health vary by welfare state regime. Similarly, there are few ross-national studies of inequalities in health whih examine gender differenes by welfare state type. What this study adds The relationship between gender and self-assessed health varies by welfare state in the majority of ases, women reported worse health than men. Women in the Soial Demorati and Southern welfare states were more likely to report worse self-assessed health than men. In the Corporatist ountries, there were no gender differenes in self-assessed health. Findings were mixed for the Liberal regime ountries. There was no onsistent welfare state regime patterning for gender differenes in self-assessed health by soioeonomi position. Although, in some ountries (Italy, Portugal, Sweden), women s relatively worse self-assessed health tended to be most prominent in the group with the highest level of eduation. Poliy impliations The poliy impliations of the study are that poliies whih target gender soialisation and traditional gender roles need to be implemented more extensively in all welfare state regimes. Traditional welfarist poliies (eg, inome redistribution) annot adequately overome gender-based inequities in health without aompanying hanges at the ultural and soietal levels. Poliies whih target gender soialisation and traditional gender roles, suh as the reommendations of the Swedish Eduation Ministry s Delegation for Gender Equality in Preshool, may be benefiial in this regard. Publi poliy interventions need to ompensate more adequately for the lak of support experiened by working women. This may require more extensive soialised hildare, as well as enhaned flexibility around working hours. 42 J Epidemiol Community Health 2009;63: doi: /jeh J Epidemiol Community Health: first published as /jeh on 3 September Downloaded from on 19 June 2018 by guest. Proteted by opyright.

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