Promoting gender equality in health. Lesley Doyal, Sarah Payne and Ailsa Cameron School for Policy Studies University of Bristol

Promoting gender equality in health Lesley Doyal, Sarah Payne and Ailsa Cameron School for Policy Studies University of Bristol

Equal Opportunities Commission 2003 First published Autumn 2003 ISBN 1 84206 095 3 EOC RESEARCH DISCUSSION SERIES & WORKING PAPER SERIES The EOC Research Discussion Series and the Working Paper Series provide a channel for the dissemination of research carried out by externally commissioned researchers. The views expressed in this report are those of the authors and do not necessarily represent the views of the Commission or other participating organisations. The Commission is publishing the report as a contribution to discussion and debate. Please contact the Research and Resources Unit for further information about other EOC research reports, or visit our webpage: Research and Resources Unit Equal Opportunities Commission Arndale House Arndale Centre Manchester M4 3EQ E-mail: research@eoc.org.uk Telephone: 0161 838 8340 Webpage: www.eoc.org.uk/research This report can be obtained in electronic format from the EOC website or in paper format from the EOC s Helpline as follows: Website: E-mail: www.eoc.org.uk info@eoc.org.uk Fax: 0161 838 8312 Helpline: 0845 601 5901 Post: EOC Arndale House Arndale Centre Manchester M4 3EQ Interpreting service available for callers to the Helpline Typetalk service available Tel: 18001 0845 601 5901 ii

CONTENTS BOXES AND FIGURES EXECUTIVE SUMMARY Page i iii 1. INTRODUCTION AND METHODOLOGY 1 1.1 Introduction 1 1.2 Methodology 1 1.3 Structure of the report 2 2. SEX, GENDER AND HEALTH 3 2.1 The impact of sex differences on health and illness 3 2.2 The impact of gender on patterns of health and illness 4 2.3 Gender differences in health care 5 2.4 Conclusion 6 3. GENDER DIFFERENCES IN HEATH STATUS AND HEALTH CARE 7 3.1 Introduction 7 3.2 Life expectancy and mortality 7 3.3 Gender differences in use of health care services 13 3.4 Gender differences in health behaviour 17 3.5 Conclusion 20 4. SEX AND GENDER IN NHS MODERNISATION POLICIES 22 4.1 Introduction 22 4.2 Putting modernisation into practice 22 4.3 Promoting greater equality in health and health care 23 4.4 Are NHS modernisation and equalities policies gender blind? 24 4.5 Policies for the new NHS: case studies of gender blindness 25 4.6 Conclusion 35 5. GENDER MAINSTREAMING IN THE NHS 36 5.1 The case for gender mainstreaming in the NHS 36 5.2 Improving the knowledge base of health status and health care needs 38 5.3 Putting sex and gender into medical research 39 5.4 Good practice in the delivery of gender sensitive health care 40 5.5 Putting gender into quality assurance 42 5.6 Decision making and public accountability: achieving a gender balance 43 5.7 Conclusion 44 6. CONCLUSION 45 REFERENCES 48 iii

INTRODUCTION AND METHODOLOGY BOXES AND FIGURES Page BOXES 2.1 Biological differences between the sexes: some examples 4 2.2 Gender differences in health and illness: some examples 5 4.1 Gender critique of NSF Coronary Heart Disease standards 28 FIGURES 3.1 Male and female life expectancy: England, 1999 8 3.2 Ratio of male: female death rates: England and Wales, 2001 9 3.3 Death rates for selected causes: England, 2001 9 3.4 Death rates for most common circulatory diseases: England, 2001 10 3.5 Death rates by type of cancer: England, 2001 11 3.6 Levels of health of the population: England, 2001 12 3.7 Admissions to NHS hospitals under mental illness specialities: England, 2001-02 14 3.8 Out-patient referral rates for selected clinical specialty: England and Wales, 2000 15 3.9 NHS GP consultations per annum by ethnic group: England, 1999 16 3.10 Percentage of persons smoking cigarettes by age: England, 2001 17 3.11 Percentage of persons consuming more than recommended weekly intake of alcohol: England, 2001 19 1

INTRODUCTION AND METHODOLOGY EXECUTIVE SUMMARY Introduction Gender issues are getting increasing attention on national and international health policy agendas. Two arguments have been used to justify this new focus. Equity principles require that women and men be given equal opportunities to realise their potential for health, while efficiency concerns demand that attention is paid to both sex and gender as determinants of health. The impact of sex and gender on health and health care Biological or sex differences between women and men affect their need for health care. Women s reproductive capacities give them special needs relating to fertility control, pregnancy and childbirth. But there is also a growing volume of evidence to show that biological differences go far beyond the reproductive system with genetic, hormonal and metabolic variations affecting male and female patterns of heart disease, infections and a range of auto-immune problems. Health is also shaped by social gender. Differences in the living and working conditions of women and men and in their access to a wide range of resources put them at differential risk of developing some health problems, while protecting them from others. Gender also influences the experiences of women and men as users of health care. Differences in the health of women and men UK statistics show that there are significant differences between women and men in both health status and use of services. However, all these differences are mediated in complex ways by differences in income and social class, age and ethnicity. When compared with men in the same social class, women in the UK have a longer life expectancy than men. This is a reflection of both biological and social differences. Men are more likely than women to die prematurely from heart disease, for example, as well as having higher mortality from lung cancer and from injuries, poisoning and suicide. Differences in male and female patterns of morbidity or sickness are more difficult to measure, but national survey results suggest that women are slightly more likely than men to report that they have recently experienced ill-health. 2

INTRODUCTION AND METHODOLOGY Women are slightly more likely than men to be admitted to hospital and they also make more use of GP services than men, but the gender gap is small. Women and men also differ in their patterns of health related behaviour; men have traditionally smoked more cigarettes and consumed more alcohol than women, for instance. Sex and gender in NHS modernisation strategies The dominant theme of much recent health policy has been modernisation. The stated aim of these changes has been to achieve increased efficiency and effectiveness, improved quality of care, devolution of control to frontline professionals, more flexibility in delivery and greater involvement of consumers in managing the service. An equalities agenda has run alongside that of modernisation. However, a detailed review of policies reveals that in practical terms, sex and gender concerns have received very little attention. While there is some recognition of special needs for women, such as family planning or breast screening, there appears to be little or no recognition of the need for gender sensitivity in mainstream services. This gender blindness is evident in the key documents published by the Department of Health: The NHS Plan, A plan for investment, A plan for reform (Department of Health, 2000d) and Saving lives: Our Healthier Nation (Department of Health, 1999c). Neither include gender equity as a goal to be pursued and differences between women and men are not built into performance targets or monitoring strategies. Similar lack of attention is evident in the work of the new agencies set up to advance the modernisation agenda including the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI). The new National Service Frameworks (NSFs) show little awareness of gender issues despite much recent evidence concerning the different needs of women and men in the context of heart disease, mental health and sexual health in particular. The case for gender mainstreaming in the NHS Both sex and gender have obvious impacts on health and health care, yet most NHS modernisation policies have been gender blind. In order to address this deficiency, the NHS would have to adopt a strategy of gender mainstreaming. The concept of gender mainstreaming has been increasingly adopted in both private and public sector organisations. The argument for this approach was initially an equity one, but the last few years have also seen the emergence of a business case for tackling gender discrimination in the workplace. Some aspects of gender mainstreaming have been incorporated into NHS employment policies as staffing problems have exerted 3

INTRODUCTION AND METHODOLOGY increasing pressure on old ways of working. However, there has been little evidence of mainstreaming in service delivery. The equalities case for gender sensitivity in the way services are delivered in the NHS has been well developed. Groups of women have campaigned for many years against what they have often experienced as discriminatory and sexist practices. In recent years, they have been joined by a number of men who believe they are not receiving the most sensitive and appropriate services. The business case for gender mainstreaming in service delivery remains largely unexplored. However, it is increasingly evident that failure to pay attention to differences between women and men will lead to inappropriate and less than optimal care. This in turn will mean that scarce resources are wasted. Putting gender mainstreaming into practice in the NHS A strategy is needed to ensure that more attention is paid to gender issues in planning and policy implementation. This should draw on examples of good practice from within the NHS itself and from health care systems in other countries. This will help to improve the effectiveness and efficiency of both the equalities and the modernisation agendas of the NHS. If the planning of services is to be optimised, methods of data collection will need to reflect the differences between women and men more fully. It is necessary to ensure that there is greater disaggregation by gender of routine health and health care data in official statistical sources. More sensitive indicators will also be needed to help in the understanding of differences in the health status of women and men and in their experiences of health care. In addition, there should be greater sensitivity to sex and gender issues in medical research. If the clinical requirements of all potential users are to be met as effectively as possible, research subjects need to be more representative of the population. Sex and gender sensitivity will need to be included in criteria for funding, researchers will require appropriate training and equity issues will have to be included on the agenda of ethics committees. If the NHS is to deliver health care which is sensitive to the needs of the whole population, all health care workers must be properly prepared. They will need to learn about gender issues in their initial training, but also as part of later professional development. Within the health service, there is now considerable expertise in the development of race awareness and this could be used to develop similar initiatives on gender. Wider organisational learning will also be required with the dissemination 4

INTRODUCTION AND METHODOLOGY of examples of good practice in the gender field to those working at all levels of the service. A major theme of the NHS modernisation agenda has been the introduction of mechanisms for quality assurance and, here too, gender concerns should be integrated. The work of both NICE and CHI would be improved if these issues were to be more fully incorporated into the surveys and technical review processes which they undertake. Finally, it will be important to ensure that both women and men are active participants in the running of the NHS. The Commission for Patient and Public Involvement in Health has overall responsibility for ensuring that users are more involved in managing the service. Mechanisms are required to ensure that equal numbers of women and men participate in this process, while appropriate groups should be encouraged to represent their special interests. The NHS and wider debates on gender equity Debates about gender equity in the NHS should be put into the broader context of equality policies in the public sector. There is evidence that these are generally fragmented and uncoordinated, with progress being dependent mostly on individual enthusiasm rather than organisational commitment. One way to improve this situation would be for the government to introduce a public sector duty to promote gender equality, preferably as part of a wider duty relating to other potentially disadvantaged groups. The creation of a statutory framework of this kind would provide a firmer foundation for the incorporation of gender issues into the modernisation agenda of the NHS and other public sector organisations. 5

INTRODUCTION AND METHODOLOGY 1. INTRODUCTION AND METHODOLOGY 1.1 Introduction In recent years, gender issues have been given greater attention on both national and international policy agendas. This has been evident across a number of different settings, but has been especially visible in the health field. Two arguments have been used to justify this new focus. First, principles of distributive justice require that women and men be given equal opportunities to realise their potential for health through access to appropriate care. Second, the more pragmatic goal of optimising the efficiency and effectiveness of services will not be achieved unless the differences between women and men are taken seriously. Both these arguments are increasingly accepted in the international health arena. The World Health Organisation (WHO) has frequently stressed the importance of gender equity issues, while the World Bank has led the way in building the economic case for gender sensitive health care (WHO, 1998; World Bank, 1993). In response to these developments, policy makers and practitioners in many parts of the world are now beginning to reshape the services they deliver. However, little has so far been done to address these issues in the UK. Though the modernisation process has called for radical rethinking on a number of fronts, gender issues have rarely been included in the paradigm for change. This research was commissioned by the EOC in February 2003 to fill this gap by increasing awareness of: the key gender issues within health; how a gendered approach could benefit both individual women and individual men; how gender analysis and mainstreaming could relate and contribute to core government objectives in public service delivery; the key changes needed if gender is to be effectively mainstreamed within health policy and health service provision; the potential benefits of a public duty in gender as it would affect health policy and health service provision. 1.2 Methodology The project began with a scoping review of a number of intersecting literatures both from the UK and from other parts of the world. This included a broad range of material on sex and gender as determinants of health and health care, with a 6

INTRODUCTION AND METHODOLOGY particular focus on debates concerning gender equity and good practice in the delivery of gender sensitive services. In the specific context of the UK, a review was then undertaken of statistical information on differences in male and female patterns of health and illness and use of services. This was followed by an analysis of the extent to which gender issues have been integrated into recent strategies for modernisation in the NHS. This was achieved through a brief review of the gender sensitivity of the key policy initiatives making up the government s modernisation agenda. The work of two key new agencies (the National Institute for Clinical Excellence and the Commission for Health Improvement) was discussed. Three of the recently published National Service Frameworks (coronary heart disease, mental health and sexual health and HIV) were also selected for consideration as being important clinical areas that raised key issues of sex and gender difference. 1.3 Structure of the report Chapter 2 clarifies the role of both biological sex and social gender in shaping patterns of health and health care. Chapter 3 examines differences in the health status and service use of women and men in GB. Chapter 4 explores the extent to which these have been taken into account in the NHS modernisation agenda. Chapter 5 makes the case for a more positive commitment to gender mainstreaming in the NHS and sets out a programme for achieving this. Chapter 6 concludes by placing the NHS in the context of broader debates about gender equality issues in the public sector. Statistical sources in the report focus mainly on England and (to a lesser extent) Wales with relatively little data from Scotland being presented. Similarly, most of the policy initiatives and ideas for mainstreaming discussed in Chapters 4 and 5 apply specifically to England and Wales. However, gender issues within health and health care are broadly similar in the three countries and similar principles could be adapted to the Scottish context where health policy is devolved. 7

SEX, GENDER AND HEALTH 2. SEX, GENDER AND HEALTH Although many health care systems are trying to move towards greater gender sensitivity, there is still considerable confusion about how this should best be done (Doyal, 2001). If appropriate policies are to be put in place, two important questions need to be answered: what are the differences in male and female experiences of health and health care and how should these be reflected in the delivery of services? There are marked differences in male and female patterns of morbidity and mortality. In most (but not all) parts of the world, women live longer than men and this gap in life expectancy is greatest in the richest countries (UNDP, 2003). On the other hand, women in many countries (especially the poorest) experience greater sickness and disability over a lifetime. There are also significant differences in the types of health problems faced by women and men. They often suffer and die from different diseases and experience illness in different ways. The reasons behind these variations are complex and they come from both the biological and the social realms. The health of males and females is clearly shaped by their biological sex. However, socially constructed gender roles also have a major impact on well-being. These factors intersect in complex ways with age, race, class and ethnicity to determine the health care needs of individual women and men. 2.1 The impact of sex differences on health and illness It is widely recognised that women s reproductive capacities give them special needs for health care. Unless they are able to control their fertility and go safely through pregnancy and childbirth, their health may be seriously damaged. This reality has long been recognised through the provision of specialist services including family planning and obstetric care. Women and men are also at risk of suffering from sexspecific problems which affect particular organs: cancers of the prostate and cervix, for example. But there is also a growing volume of evidence to show that these biological differences between women and men go beyond the reproductive system (Wizemann and Pardue, 2001). Marked differences exist in the incidence, symptoms and prognosis of a wide range of diseases and conditions that affect both sexes. This is very evident in the case of coronary heart disease, for example, which affects more men than women at younger ages. It is also reflected in the epidemiology of some infectious diseases, including tuberculosis to which men appear to be inherently more susceptible. Recent studies indicate that these variations are due in large part to previously unrecognised genetic, hormonal and metabolic differences between men and women (Wizemann and Pardue, 2001). 8

SEX, GENDER AND HEALTH Box 2.1 Biological differences between the sexes: some examples Men typically develop heart disease ten years earlier than women. Women s immune systems make them more resistant than men to some kinds of infection including tuberculosis. Women are around 2.7 times more likely than men to develop an autoimmune disease such as diabetes. Male-to-female infection with HIV is more than twice as efficient as female-to-male infection. Source: Wizemann and Pardue (2001). 2.2 The impact of gender on patterns of health and illness Biology is not the only factor shaping differences in male and female patterns of morbidity and mortality. There is also an extensive literature documenting the relationship between gender and health (Hunt and Annandale, 1998; Denton and Walters, 1999). Despite the obvious similarities in the lives of women and men from the same social group, there may also be marked differences which can have significant effects on their well-being. Gender differences in living and working conditions and in access to a wide range of resources put males and females at differential risk of developing some health problems, while protecting them from others. Many studies have shown that the domestic responsibilities usually associated with female gender can have a negative impact on both physical and mental health (Doyal, 1995). The higher levels of depression and anxiety reported by women have been explained in part by reference to their work in caring for others with what may be insufficient amounts of time, money and other resources. This is especially true for those women raising their families in poverty. Gender violence has also been highlighted as a major public health hazard for women around the world (Heise et al, 1994). As the links between women s lives and their health are given greater attention, the potential health risks of masculinity are also beginning to emerge (Luck et al, 1999; Courtenay and Keeling, 2000). At first glance, being male might seem to be a privilege which gives greater access to health promoting resources. However, it may also require the taking of risks. The traditional role of breadwinner means that men 9

SEX, GENDER AND HEALTH are still more likely than women to die prematurely from occupational disease and injuries. Again, this is especially true of men attempting to survive in conditions of poverty. As a result of their socialisation into masculinity, men in most societies have also been more likely than women to engage in dangerous activities including smoking, excessive drinking, dangerous driving and unsafe sex. Box 2.2 Gender differences in heath and illness: some examples Men are more likely than women to commit suicide. Both community based studies and statistics on service use show that women are 2-3 times more likely than men to be affected by depression or anxiety. Men are more likely than women to die of injuries, but women are more likely to die of injuries sustained at home. The gap between male and female smoking rates is beginning to narrow as young women are taking up the habit more frequently than young Source: Wizemann and Pardue (2001). 2.3 Gender differences in health care As well as being a major determinant of health itself, gender also influences the experiences of women and men as users of health care. Women are more likely than men to report practical problems in access to services. They are more likely to have caring responsibilities, for example, or to have transport problems (Broom, 1995; Doyal, 1998; Hamilton et al, forthcoming). Men, on the other hand, may find it more difficult to admit weakness, or to accept that they may be ill and hence may delay longer before seeking medical advice (Cameron and Bernardes, 1998; Sabo and Gordon, 1995; Watson, 2000). Once in receipt of care, there also appear to be gender differences in how women and men are treated (Beery, 1995; Foster and Malik, 1998; Wenger, 1997). Studies from a number of different countries have shown that health workers may make different diagnoses of men and women on the basis of similar evidence. They may also offer different treatment in what would appear to be the same clinical situations (Shaw et al, 2000). For example, women under 65 have more unrecognised myocardial infarctions than men (McKinley, 1996). Women are less often referred to acute catheterisation, coronary angioplastry, thrombolysis or coronary bypass surgery, despite evidence that such procedures are as effective for women as men (Wenger, 1997; Mark, 2000). 10

SEX, GENDER AND HEALTH 2.4 Conclusion Both sex and gender are therefore important determinants of health. Like ethnicity, age and class, they are important in shaping morbidity and mortality as well as influencing access to services and quality of care. The next chapter will examine the ways in which these differences are reflected in the health status of women and men in the UK and in their experiences of the NHS. 11

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE 3. GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE 3.1 Introduction The growing body of information on sex and gender differences in health and health care in Britain in official statistical sources published by the Department of Health and others is reviewed in this chapter. However, this evidence remains partial and difficult to interpret in some areas. Hence it is also important to identify gaps in the available data as well as limitations on our capacity to understand the existing information without further research. Differences in mortality and morbidity between women and men do not vary greatly across Britain and for that reason the data used will refer mainly to populations in England. However, gender differences in health and illness do vary in relation to class and ethnicity. While space does not allow for a detailed account of these intersections, examples will be given where they are deemed most relevant. 3.2 Life expectancy and mortality Life expectancy The most obvious difference between women and men is in the area of life expectancy. Women in all countries in the UK have a longer life expectancy than men. In England in 1999, life expectancy at birth for a female child was 80.2 years, compared with 75.8 for a male (see Figure 3.1). This gap results from biological factors including the greater susceptibility of men to specific conditions, combined with a range of gender related factors including differences in male and female patterns of health-related behaviour. Life expectancy also varies by social class. In England and Wales, life expectancy for female children at birth in the highest occupational group in 1992-96 was 83. This compared with 77 for females in the lowest occupational group. For male children there was a ten-year gap, with males in the highest group having a life expectancy of 78, compared with a life expectancy of 68 for males in the lowest class (Office for National Statistics (ONS), 2002). 12

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Figure 3.1 Male and female life expectancy: England, 1999 90 80 70 60 50 40 30 20 10 0 At birth 5 20 30 50 60 70 80 Male Female Note: Source: Selected ages. Department of Health (2003a), Health and Personal Social Services Statistics, Tables A1-A2. Mortality The male death rate in England and Wales in 2001 was 989.6 per 100,000 population compared with a rate of 1033.9 for women. Overall death rates for women and men are very similar, and rates for both have been falling slowly over time. However, death rates for women have exceeded those of men since the 1990s, due to the greater proportion of women among the very old. Although similar overall, death rates vary substantially by age group, and there are marked differences in the risk of death at different ages for men and women (see Figure 3.2). Figure 3.2 expresses male deaths as a percentage of female deaths that is, 100 implies equal mortality for men and women, whilst values above 100 reflect greater male mortality. Male mortality rates are higher than female rates virtually throughout the life course, though the extent of this male excess varies. There is a slightly increased risk of death amongst males compared with females in the first years of life, but it is in youth and early adulthood that excess deaths in men are most notable. 13

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Figure 3.2 Ratio of male: female death rates: England and Wales, 2001 300 250 200 150 100 50 0 All ages Note: Under 1* Male deaths as a percentage of female deaths. 85 and over Source: Office for National Statistics (2003), Population Trends, Table 6.1. Figure 3.3 Death rates for selected causes: England, 2001 450 400 350 300 250 200 150 100 50 0 All circulatory disease All malignant neoplasms Bronchitis & allied conds Pneumonia All accidents and adverse effects Male Female Note: Source: Rates per 100,000 population. Department of Health (2003a), Health and Personal Social Services Statistics, Tables A3-A4. There are important differences in causes of death between women and men. Across the UK, the major killers for both groups are cancer and circulatory diseases. In 14

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE England, for example, 39 per cent of men and 38 per cent of women die from circulatory disease. However, whilst overall deaths from circulatory disease are similar for women and men, females are more likely than males to die from the cerebrovascular disease associated with older age, whilst male deaths are higher for ischaemic heart disease (see Figure 3.4). This is reflected in age-related differences in mortality, with higher female mortality for those conditions associated with increasing age. Figure 3.4 Death rates for most common circulatory diseases: England, 2001 250 200 150 100 50 0 Ischaemic heart disease Cerebrovascular disease Male Female Note: Source: Rates per 100,000 population. Department of Health (2003a), Health and Personal Social Services Statistics, Tables A3-A4. Cancer morta lity also varies between women and men (see Figure 3.5). There is excess male mortality from lung cancer in particular, which relates to higher levels of tobacco use amongst men (see pp. 17-18), and also from stomach and colon cancer. The number of deaths from less common causes also differs between men and women. Female death rates are much lower than those of males for injuries, poisoning and suicide. Deaths from suicide, for example, are more than three times greater in men than in women. In 2001, more men than women died as a result of accidental injury, while male deaths as a result of road accidents were nearly three times the number for women. The number of male deaths from chronic liver disease and cirrhosis was nearly twice the number of female deaths (Department of Health 2003a, Table A3-A4). 15

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Figure 3.5 Death rates by type of cancer: England, 2001 80 70 60 50 40 30 20 10 0 Stomach Colon etc Pancreas Lung Prostate Breast Uterus Male Female Note: Source: Rates per 100,000 population. Department of Health (2003a), Health and Personal Social Services Statistics, Tables A3-A4. Male and female patterns of morbidity Whilst there are clearly identifiable differences between male and female patterns of mortality, differences in ill-health and morbidity are more complex and difficult to interpret. This is partly because ill-health itself is much harder to measure. In this section, the differences between male and female health status are explored through the answers given to self-report questions in a number of health surveys in the UK. Figure 3.6 suggests that there are few differences in health status between women and men. The Health Survey for England (Department of Health, 2001a) found that three quarters of the population, both male and female, reported their health to be either good or very good. Slightly more women reported acute ill-health (illness in the fortnight before the survey interview) and there has been a consistent gap of around 4 per cent in the responses of women and men to this question over the last eight years. The 1998 Welsh Health Survey (The National Assembly for Wales, 1999) asked questions concerning long-term limiting illness. The survey used the standard question found in other studies including the 2001 UK Census. Overall, 34 per cent of men and 35 per cent of women reported such illness. This finding which has been replicated in a number of other studies (for example, the General Household Survey and the Census) casts doubt on the common belief that women in the UK are more likely than men to suffer poor health. However, the complexities inherent in the measurement of differences in the health status of women and men are only beginning to be understood. Figure 3.6 Levels of health of the population: England, 2001 16

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE 80 70 60 50 40 30 20 10 0 Very good/good health Very bad/bad health At least one longstanding illness Acute sickness Male Female Note: Source: Percentage of population reporting condition. Department of Health (2001a), Health Survey for England, Table A.5. Recent studies show that women and men may assess their health according to different criteria, such as ability to get through the day compared with being physically fit, and this is reflected in the findings from self-report surveys (e.g. Curtis and Lawson, 2000; Macintyre et al, 1999). It is also clear that gender differences in reported morbidity vary according to the age, level of domestic commitments and paid work of those being questioned (Matthews et al, 1998; Walters et al, 2002; Arber and Khlat, 2002). Hence it is difficult to draw definitive conclusions about gender differences in health status from the simple questions used in surveys of this kind. In addition to self-report data, clinical measurements of health are also available from the annual Health Survey for England. These include information on conditions such as hypertension and obesity, which may be indicative of increased risk of heart disease, stroke and possibly some cancers (in the case of obesity). In 2001, the Health Survey for England found that 41 per cent of men and 35 per cent of women had high blood pressure. The majority of those with hypertension were not receiving treatment. Morbidity also varies in relation to class and deprivation. Key Health Statistics from General Practice 1998 (ONS, 2000a) gives details of the prevalence of key health conditions in England and Wales for both women and men. These data show, for example, that whilst the age standardised male prevalence of treated coronary heart disease in 1998 was 35.8 per 1,000 patients for England and Wales as a whole, the rate for women was 21.3. However, for both women and men, prevalence varied in relation to levels of deprivation, with the highest rates in deprived industrial areas for 17

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE both men (44.6 per 1,000 patients) and women (29.7) and the lowest in what the Office for National Statistics (2000a) describe as prosperous areas. Finally, morbidity data also show a relationship between ethnicity and health amongst both women and men. The 1999 Health Survey for England found levels of limiting long-standing illness were higher for both men and women in Black Caribbean, Pakistani, Bangladeshi and Irish groups and also for Indian women, whilst rates were lower amongst both Chinese men and women. Levels of both limiting illness and long-standing limiting illness were also higher amongst minority ethnic men and women in lower occupational groups (Department of Health, 2001a). 3.3 Gender differences in use of health care services Figures for both primary care and hospital services show different patterns of use for women and men. In patient treatment Women are more slightly more likely than men to be admitted to hospital as inpatients (ONS, 1998). These figures also reveal differences between women and men by ethnic group. Men from most ethnic minorities have slightly lower rates of inpatient treatment compared with women in the same group (Dench et al, 2002). However, data from the Health Survey for England (1999) show that when maternity services are excluded, Indian and Pakistani men have higher rates of in-patient hospital treatment than women in the same group. For Indian women and men the difference is especially high. In 1999, fewer than 1 per cent of Indian women entered hospital as in-patients, compared with 7 per cent of men. This is difficult to explain. Self-reported health amongst Indian women is lower than for other groups, and Indian women have relatively high levels of self-reported longstanding conditions such as those related to the nervous and musculoskeletal system (Dench et al, 2002). Indian women s lower rates of hospital care may be explained by a complex set of factors. These include cultural differences, which result in lower consultation rates in primary care for disorders that can lead to hospital referral, and higher probability of non-attendance for hospital appointments due to anxieties over male doctors and concerns over the availability of interpreters (Hussain and Cochrane, 2003; Firdous and Bhopal, 1989; Mhadok et al, 1992). Chapple et al (1998) for example discuss Asian women s lower rate of consultation for menstrual disorders. Asian women were more likely to be referred to hospital by their GP, but also were more likely not to attend hospital appointments due to anxieties over language and not being able to see a female doctor. Another study found that amongst women and men admitted to hospital following head injury, South Asian women had significantly shorter in-patient stays than white women, whilst the reverse was true for men. However, no explanation was offered for these differences (Moles et al, 1999). There are also differences between women and men in hospital treatment for mental health problems. In-patient data reveal higher admission rates amongst men in early life and again in old age, while female rates are higher in middle age (see Figure 3.7). 18

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Figure 3.7 Admissions to NHS hospitals under mental illness specialities: England, 2001-02 14 12 10 8 6 4 2 0 Under 15 15-19 20-24 25-44 45-64 65-74 75-84 85+ All ages Male Female Note: Rate per 1,000 population. Source: Department of Health (2002b), Hospital Episode Statistics, Table B25. This pattern of male over-representation in younger and older age groups is relatively recent. Until the early 1980s, more women than men were admitted to psychiatric hospital. Since that time there has been a marked change with younger men and those over 75 experiencing an increased risk of hospitalisation for psychiatric illness (Payne, 1996; 1998). Out-patient treatment Patterns of hospital attendance as outpatients also vary between women and men. Though they have similar numbers of visits, men are more likely than women to attend accident and emergency departments. Age-standardised data from the Key Health Statistics from General Practice (ONS, 2000a) reveal that women had higher rates overall of GP referrals for out-patient appointments. However, the sex ratio varied between clinical specialities, with higher rates of referral for in-patient treatment for women in general surgery, general medicine and psychiatry in particular (see Figure 3.8). 19

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Figure 3.8 Out-patient referral rates for selected clinical specialty: England and Wales, 2000 35 30 25 20 15 10 5 0 General medicine General surgery Orthopaedic Gynaecology Psychiatry Male Female Note: Age standardised rates for 1,000 patient years at risk. Source: Office of National Statistics (2000), Table 5B1. Again, these gender differences vary by ethnic groups. The 1999 Health Survey for England showed that more men than women had attended hospital in the past year in all ethnic groups other than Black Caribbean, where male and female attendance rates were equivalent. However, both Chinese women and Chinese men were less likely to have attended as out-patients compared with the general population (Dench et al, 2002). This reflects lower rates of GP consultation, and also higher proportions of the Chinese population reporting their health as either good or very good, compared with other groups (Dench et al, 2002). Chinese men and women are less likely to report being affected by a number of key health conditions, including those which may lead to hospital referral, such as cardiovascular and metabolic disease and diabetes (Department of Health, 2001a). GP consultations Data for Britain show that women make more use of GP services than men, but the differences are small. In 2000, women made an average of five visits per year compared with an average of four for men. Not surprisingly, the gap between women and men was greater in the reproductive years; women aged 16-44 made an average of five GP visits per year compared with only three for men of the same age. The number of consultations rose with age for both women and men (Dench et al, 2002). Figures from the General Household Survey for consultations in the two weeks prior to interview, suggest that around 18 per cent of women are likely to have seen their GP in this period, compared with 12 per cent of men (ONS, 1998). However, these differences need to be seen in the wider context of both social class and ethnic 20

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE variations in consultation rates. Women consult GPs more frequently than men, in all ethnic groups other than those from Bangladesh. The female: male ratio is highest amongst the Pakistani and Irish groups (see Figure 3.9). Figure 3.9 NHS GP consultations per annum by ethnic group: England, 1999 10 9 8 7 6 5 4 3 2 1 0 Black Caribbean Indian Pakistani Bangladeshi Chinese Irish General population Male Female Note: General population includes individuals from white and ethnic minority groups. Source: Dench et al (2002), Table 8.44. 3.4 Gender differences in health behaviour Women and men differ not only in their use of services, but also in their patterns of health-related behaviour such as exercise, food and alcohol consumption and smoking. These behavioural differences are mediated by social class and by ethnicity, and also vary over time. Smoking There are significant differences between women and men in patterns of tobacco use. 21

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Figure 3.10 Percentage of persons smoking cigarettes by age: England, 2001 40 35 30 25 20 15 10 5 0 16-24 25-44 45-64 65+ Male Female Source: Department of Health (2003a), Health and Personal Social Services Statistics, Table A7. As Figure 3.10 shows, similar percentages of both women and men smoke in the younger age groups, whilst there are more male smokers aged 25-44 and 45-64. Women then predominate over the age of 65. The 1998 Welsh Health Survey (The National Assembly for Wales, 1999, Appendix 3) reported that 29 per cent of men and 25 per cent of women were smokers, with the highest percentages in younger age groups. The 1998 Scottish Health Survey found that 34 per cent of men and 32 per cent of women currently smoked, with higher rates in younger age groups (Boreham, 2000). Rates of smoking also vary by social class and ethnicity. The 1998 General Household Survey revealed that both women and men in lower income groups are more likely to smoke, with 36 per cent of men and 31 per cent of women in manual occupations being current smokers, compared with 15 per cent of men and 14 per cent of women in professional occupations (Office for National Statistics, 2000b). Data on smoking by ethnic group for England reveal that Black Caribbean women and men are more likely than the general population to be light smokers (under 20 a day), but are less likely to smoke more than 20 a day (Dench et al, 2002). There has been considerable concern over the extent to which younger women may be taking up smoking and the likely impact of this on their health. Changing patterns of tobacco use take some time to be reflected in mortality patterns, but there are already signs of increases in lung cancer and other tobacco related diseases amongst women in Britain. Findings from a 2001 survey of young people in England indicated that 11 per cent of girls aged 11-15 were regular smokers, compared with 8 per cent of boys, and 20 per cent of girls were either regular or occasional smokers, compared with 15 per cent of 22

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE boys (Department of Health, 2003a, Table A8). Similarly, 11 per cent of secondary school boys in Scotland smoked in 1998, compared with 13 per cent of girls (cited by Boreham, 2000). In Wales too, girls are more likely to smoke than boys. In 2000, 6 per cent of 13-14 year-old boys reported that they smoked on a weekly basis, compared with 17 per cent of girls in the same year group, whilst 30 per cent of girls aged 15-16 reported smoking on a weekly basis, compared with 20 per cent of boys (The National Assembly for Wales, 1999). Whilst girls have been more likely to smoke than boys, this very high proportion of girls smoking in Wales is both surprising smoking rates amongst adult women in Wales are not higher than in other parts of the UK and worrying. These figures suggest a major problem is likely in the future for all kinds of health outcomes for women. Alcohol use Figures for alcohol consumption also show different patterns for women and men. As Figure 3.11 shows, men in all age groups are more likely than women in England to consume more than the recommended number of units per week. Overall, 27 per cent of men and 15 per cent of women were found to consume more than the recommended total. The difference between women and men remained fairly constant across the age groups despite suggestions that women s alcohol intake has increased in recent years. Department of Health data for England suggest that the proportion of women drinking above the recommended 14 units a week has not changed since 1998 (Department of Health, 2001a). In the 1998 Scottish Health Survey, 32 per cent of men and 14 per cent of women between the ages of 16 and 74 reported a weekly consumption over recommended limits. The highest proportion of those consuming in excess of the recommended amounts was found in the younger age groups. Forty-three per cent of men and 24 per cent of women aged 16-24 reported a weekly consumption over suggested limits (Erens, 2000). In the 1998 Welsh Health Survey, 19 per cent of men and 8 per cent of women were reported to consume harmful levels of alcohol (The National Assembly for Wales, 1999). These figures are considerably lower than those found for England and Scotland. However, the Welsh study used self-completion forms rather than interview schedules and this may have encouraged respondents to under-estimate alcohol consumption. Figure 3.11 Percentage of persons consuming more than recommended weekly intake of alcohol: England, 2001 50 45 40 35 30 25 20 15 10 5 0 18-24 25-44 45-64 65+ Total 23 Male Female

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE Note: Source: Recommended maximum intake is 14 units for women and 21 for men. Department of Health (2003a), Health and Personal Social Services Statistics, Table A7. Substance misuse Gender differences in substance misuse are difficult to measure since so much is concealed, especially among women who are likely to be more stigmatised. Data which come from use of services are also likely to underestimate the numbers of women, as women are less likely to attend drug services. In England, these data suggest that around three times as many men as women sought help in the six month period ending March 2001 (Department of Health, 2003a, Table A10). In Scotland, in 2001-02, 67 per cent of service users were male and 33 per cent were female (Drug Misuse Information Scotland, 2003). In Wales in 1996 only 25 per cent of notified drug addicts were female (Welsh Office, 1998). However, there is some evidence to suggest that these gender differences are reducing. Amongst secondary school pupils in Scotland, 16 per cent of boys and 13 per cent of girls had used drugs in the previous month (Child and Adolescent Health Research Unit, 2002). Diet Diet and lifestyle surveys now collect regular data on patterns of food consumption and again gender differences are very evident. For example, the diet of women in Scotland appears to be significantly better than that of men. They are more likely to eat vegetables, fruit and wholemeal bread and are less likely to eat fried food or have sugar in hot drinks. However, they are more likely to eat chocolate, biscuits and crisps every day (Deepchand, Shaw and Field, 2000). Similarly, in Wales only about a quarter of women have what could be called an unhealthy diet compared with a third of men (Welsh Office, 1998). Obesity and exercise Men are more likely than women to be overweight or obese. The 1998 Health Survey for Wales found that around three fifths of adult men had a body mass index (BMI) greater than 25, compared with around a half of adult women (Welsh Office, 1998). 1 In England, the 2001 Health Survey found 68 per cent of men and 56 per cent of women to be either overweight or obese (Department of Health, 2001a). However, women were less likely to participate in physical exercise on a regular basis. Recent data from Wales indicate that 90 per cent of young men (aged 16-24) participated in physical exercise in comparison with 75 per cent of women of the same age. Amongst older people, around half of both men and women reported taking part in physical activities (Welsh Office, 1998). 3.5 Conclusion This brief overview has demonstrated the influence of sex and gender on patterns of health and health care in the UK. It has also illustrated the complex ways in which these effects are mediated by differences in income and social class and by age and by ethnicity. These differences in the health and health care needs of women and men have important implications for policy interventions and the prospect that health targets will be met. 1 The BMI is a measure of obesity based on height and weight. 24