Central gender theoretical concepts in health research: the state of the art

Gender/Sex as a Social Determinant of Cardiovascular Risk

The social gradient for cardiovascular disease (CVD) onset and outcomes is well established. The American Heart Association's Social Determinants of Risk and Outcomes of Cardiovascular Disease Scientific Statement advocates looking beyond breakthroughs in biological science toward a social determinants approach that focuses on socioeconomic position, race and ethnicity, social support, culture and access to medical care, and residential environments to curb the burden of CVD going forward. Indeed, the benefits of this approach are likely to be far reaching, enhancing the positive effects of advances in CVD related to prevention and treatment while reducing health inequities that contribute to CVD onset and outcomes. It is disappointing that the role of gender has been largely neglected despite being a critical determinant of cardiovascular health. It is clear that trajectories and outcomes of CVD differ by biological sex, yet the tendency for sex and gender to be conflated has contributed to the idea that both are constant or fixed with little room for intervention. Rather, as distinct from biological sex, gender is socially produced. Overlaid on biological sex, gender is a broad term that shapes and interacts with one's cognition to guide norms, roles, behaviors, and social relations. It is a fluid construct that varies across time, place, and life stage. Gender can interact with biological sex and, indeed, other social determinants, such as ethnicity and socioeconomic position, to shape cardiovascular health from conception, through early life when health behaviors and risk factors are shaped, into adolescence and adulthood. This article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood by focusing on physical activity, drinking, and smoking behaviors (including the influence of role modeling). We will also discuss the role of gender in psychosocial stress with a focus on trauma from life events (childhood assault and intimate partner violence) and work, home, and financial stresses. We conclude by exploring potential biological pathways, with a focus on autonomic functioning, which may underpin gender as a social determinant of cardiovascular health. Finally, we discuss implications for cardiovascular treatment and awareness campaigns and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.

Gender inequalities in diet quality and their socioeconomic patterning in a nutrition transition context in the Middle East and North Africa: a cross-sectional study in Tunisia

Background

In a context of nutrition transition and major shifts in lifestyle and diet, the Middle East and North Africa features a marked gender excess adiposity gap detrimental to women. In this setting, where gender issues are especially acute, we investigated gender differences in dietary intake with a focus on diet quality, and how the differences varied with the area of residence and socio-demographic characteristics.

Methods

The study was conducted in 2009–2010 in the Greater Tunis region (Tunisia), as a case study of an advanced nutrition transition context in the region. A cross-sectional survey used a random, stratified, clustered sample of households: 1689 women and 930 men aged 20–49 years were analyzed. Dietary intake was assessed using a 3-day food record. Nutrient content was derived from a specific Tunisian food composition database. We analysed the Diet Quality Index-International (DQI-I) and sub-scores (variety, adequacy, moderation and balance). A score of DQI-I > 60 defined good diet quality. Inequality measures were women vs. men differences in means for interval variables and odds-ratios (OR) for DQI-I > 60. Their variation with socio-demographic characteristics was estimated using models featuring gender x covariate interactions.

Results

Mean energy intake/day was 2300 ± 15 kcal for women vs. 2859 ± 32 kcal for men. By 1000 g/kcal/d women consumed more fruits and sweets but less red meat and soft drinks than men. Women had a higher mean moderation sub-score than men (+ 1.8[1.4, 2.2], P < 0.0001) but lower variety (− 2.0[− 2.3, − 1.6], P < 0.0001) and adequacy (− 1.8[− 2.0, − 1.5], P < 0.0001). Thus, the overall mean DQI-I was lower among women than men (58.6 ± 0.3 vs. 60.4 ± 0.3, − 1.8[− 2.6, − 1.0], P < 0.0001) as was the proportion of DQI-I > 60 (45.2% vs. 55.7%, OR = 0.7[0.5, 0.8], P < 0.0001). Adjusted gender differences in DQI-I decreased with age but were higher in larger households and extreme categories of education (no-schooling and university) vs. the middle categories.

Conclusion

In this nutrition transition context with only average diet quality, it was somewhat lower for women. Socioeconomic patterning of gender contrasts was mild. Beyond, that women had lower adequacy and variety scores but better moderation is a possible pathway for gender specific prevention messages.

Electronic supplementary material

The online version of this article (10.1186/s12937-019-0442-6) contains supplementary material, which is available to authorized users.

[AdvanceGender-Joint project for sex/gender-sensitive and intersectional research and health reporting]

Health reporting provides information on the health of the population and thus forms the basis for adequate health promotion, prevention, and care. In order to better represent social diversity, the joint project AdvanceGender (funded by the German Federal Ministry for Education and Research) aims to promote the development of a gender-sensitive and intersectional approach to population-based studies and health reporting. The three subprojects research study participation, data analysis, and health reporting. Based on the results, recommendations for epidemiological studies and for health reporting will be developed.

Gender Perspective on Older People's Exercise Preferences and Motivators in the Context of Falls Prevention: A Qualitative Study

Background

Several factors have previously been identified to positively influence the uptake and adherence for fall prevention exercise programmes. There is, however, a lack of studies investigating if men and women differ in their views and preferences for fall prevention exercises.

Aim

To explore exercise preferences and motivators of older community-dwelling women and men in the context of falls prevention from a gender perspective.

Methods

Workshops including multistage focus group discussions were conducted with 18 older community-dwelling people with and without history of falls. Participants were purposively selected and divided into two groups. Each group met on six occasions over a period of five months. Participatory and Appreciative Action and Reflection methodology was used to guide the discussions. A qualitative content analysis approach was used in the analysis.

Results

Older participants had many diverse preferences and confirmed that individually tailored exercise, in terms of mode, intensity, challenge, and social context, is important. Moreover, important factors for exercise adherence and maintenance included the experience of individual confirmation; different spirit lifters to increase enjoyment; and personal tricks to maintain exercise routines. The individual differences within genders were more diverse than the differences between women and men.

Conclusion

Exercise interventions to prevent falls should be individually tailored, based on the specific needs and preferences of the older participant, and do not appear to require gender specific approaches. To increase adherence, intrinsic motivation for exercise may be encouraged by competence enhancing confirmations, energizing spirit lifters, and practical tips for exercise maintenance. The study provides an awareness about women's and men's preferences for fall prevention exercises, and this information could be used as guidance in designing inclusive exercise interventions.

[Integration of sex/gender into environmental health research. Results of the interdisciplinary research network Sex/Gender-Environment-Health (GeUmGe-NET)]

The comprehensive consideration of sex/gender in health research is essential to increase relevance and validity of research results. Contrary to other areas of health research, there is no systematic summary of the current state of research on the significance of sex/gender in environmental health. Within the interdisciplinary research network Sex/Gender-Environment-Health (GeUmGe-NET) the current state of integration of sex/gender aspects or, respectively, gender theoretical concepts into research was systematically assessed within selected topics of the research areas environmental toxicology, environmental medicine, environmental epidemiology and public health research on environment and health. Knowledge gaps and research needs were identified in all research areas. Furthermore, the potential for methodological advancements by using gender theoretical concepts was depicted. A dialogue between biomedical research, public health research, and gender studies was started with the research network GeUmGe-NET. This dialogue has to be continued particularly regarding a common testing of methodological innovations in data collection and data analysis. Insights of this interdisciplinary research are relevant for practice areas such as environmental health protection, health promotion, environmental justice, and environmental health monitoring.

Photovoice and empowerment: evaluating the transformative potential of a participatory action research project

BACKGROUND

Photovoice is a visual research methodology with the intention to foster social change. Photovoice has been used to investigate change in empowerment in vulnerable communities, However, the individual experience of participants involved in Photovoice projects is seldom scrutinized. Our aim was to explore and describe the individual experiences of the female individuals who participated in a previous Photovoice project. We analyzed a change in the women's empowerment in terms of: 1) gain in knowledge and skills, 2) change in self-perception, and 3) access to and use of resources.

METHODS

This qualitative study took place in the low-income District of Villaverde (Madrid, Spain), from January-June 2016. We conducted 10 semi-structured interviews with the female residents who had participated in the previous Photovoice project. We also collected field notes. We analyzed these data through a direct qualitative content analysis. The three outlined dimensions of empowerment provided guidance for the analysis of the results.

RESULTS

We found positive changes in the three dimensions of empowerment: 1) participants acquired new knowledge and developed critical awareness of their community; 2) the social recognition participants received transformed their self-perception; and 3) the project allowed them to expand their social networks and to build new links with different actors (research partners, local decision makers, media and the wider public).

CONCLUSIONS

Photovoice projects entail the opportunity for empowering participants. Future research using Photovoice should assess the influence it has on participants' empowerment changes and how to sustain these individual and social changes.

How gender theories are used in contemporary public health research

Background

Public health research often focuses on gender differences within certain diagnoses, but so far research has failed to explain these differences in a satisfactory way. Theoretical development could be one prerequisite for moving beyond categorical thinking. The aim of this paper was to analyse how gender theories have been used in public health research in relation to various methodological approaches.

Method

Six special issues of gender research with public health relevance (comprising 33 papers in total) were identified from a search of PubMed and Web of Science, spanning a 10-year period. The papers were analysed inductively through posing questions to the text.

Results

Gender theories were used in eight different ways: 1. to test hypotheses, 2. integrate theories, 3. develop gender concepts and models, 4. interpret findings, 5. understand health problems, 6. illustrate the validity of other theories, 7. integrated into a gender blind theory, as well as to 8. critique of other gender theories. The strategies applied seemed independent of the health aspects of the papers. However, the methodologies were of importance, indicating that both theoretical papers and papers using qualitative methodologies used almost all available strategies, while papers using quantitative empirical research used a limited number of strategies.

Conclusions

This study contributes to identifying how gender theories are used in contemporary public health research, which can help researchers move beyond a categorical understanding of gender in health research.

Electronic supplementary material

The online version of this article (10.1186/s12939-017-0712-x) contains supplementary material, which is available to authorized users.

From denial to awareness: a conceptual model for obtaining equity in healthcare

BACKGROUND

Although Swedish legislation prescribes equity in healthcare, studies have reported inequalities, both in face-to-face encounters and in telephone nursing. Research has suggested that telephone nursing has the capability to increase equity in healthcare, as it is open to all and not limited by long distances. However, this requires an increased awareness of equity in healthcare among telephone nurses. The aim of this study was to explore and describe perceptions of equity in healthcare among Swedish telephone nurses who had participated in an educational intervention on equity in health, including which of the power constructs gender, ethnicity and age they commented upon most frequently. Further, the aim was to develop a conceptual model for obtaining equity in healthcare, based on the results of the empirical investigation.

METHOD

A qualitative method was used. Free text comments from questionnaires filled out by 133 telephone nurses before and after an educational intervention on equity in health, as well as individual interviews with five participants, were analyzed qualitatively. The number of comments related to inequity based on gender, ethnicity or age in the free text comments was counted descriptively.

RESULTS

Gender was the factor commented upon the least and ethnicity the most. Four concepts were found through the qualitative analysis: Denial, Defense, Openness, and Awareness. Some informants denied inequity in healthcare in general, and in telephone nursing in particular. Others acknowledged it, but argued that they had workplace routines that protected against it. There were also examples of an openness to the fact that inequity existed and a willingness to learn and prevent it, as well as an already high awareness of inequity in healthcare.

CONCLUSION

A conceptual model was developed in which the four concepts were divided into two qualitatively different blocks, with Denial and Defense on one side of a continuum and Openness and Awareness on the other. In order to reach equity in healthcare, action is also needed, and that concept was therefore added to the model. The result can be used as a starting point when developing educational interventions for healthcare personnel.

Binge drinking and well-being in European older adults: do gender and region matter?

Background

We aimed to describe gender and region differences in the prevalence of binge drinking and in the association between binge drinking and well-being, among older adult Europeans.

Methods

This is a cross-sectional study using the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 4, conducted between 2011 and 2012, including 58 489 individuals aged 50 years or older. Sixteen European countries were grouped in four drinking culture regions: South, Central, North and East. We categorized drinking patterns as: never, former, no-binge and binge drinkers. We used the CASP-12 questionnaire to measure well-being. To assess the association between binge drinking and well-being, we fitted two-level mixed effects linear models.

Results

The highest percentage of binge drinkers was found in Central Europe (17.25% in men and 5.05% in women) and the lowest in Southern Europe (9.74% in men and 2.34% in women). Former, never and binge drinkers had a significant negative association with well-being as compared with no-binge drinkers. There was a significant interaction in this association by gender and region. Overall, associations were generally stronger in women and in Southern and Eastern Europe. The negative association of binge drinking with well-being was especially strong in Southern European women (β = -3.80, 95% CI: -5.16 to - 2.44, P value <0.001).

Conclusion

In Southern and Eastern European countries the association between binge drinking and well-being is stronger, especially in women, compared with Northern and Central Europe. Cultural factors (such as tolerance to drunkenness) should be further explored.

Health and legal literacy for migrants: twinned strands woven in the cloth of social justice and the human right to health care

Background

Based on an analysis of published literature, this paper provides an over-view of the challenges associated with delivering on the right to access quality health care for international migrants to industrialized countries, and asks which group of professionals is best equipped to provide services that increase health and legal literacy. Both rights and challenges are approached from a social justice perspective with the aim of identifying opportunities to promote greater health equity. That is, to go beyond the legal dictates enshrined in principles of equality, and target as an ethical imperative a situation where all migrants receive the particular assistance they need to overcome the barriers that inhibit their equitable access to health care. This assistance is especially important for migrant groups that are further disadvantaged by differing cultural constructions of gender. Viewing the topic from this perspective makes evident a gap in both research literature and policy. The review has found that while health literacy is debated and enshrined as a policy objective, and consideration is given to improving legal literacy as a means of challenging social injustice in developing nations, however, no discussion has been identified that considers assisting migrants to gain legal literacy as a step toward achieving not only health literacy and improved health outcomes, but critical participation as members of their adoptive society.

Conclusion

Increasing migrant health literacy, amalgamated with legal literacy, aids migrants to better access their human right to appropriate care, which in turn demonstrably assists in increasing social engagement, citizenship and productivity. However what is not evident in the literature, is which bureaucratic or societal group holds responsibility for assisting migrants to develop critical citizenship literacy skills. This paper proposes that a debate is required to determine both who is best placed to provide services that increase health and legal literacy, and how they should be resourced, trained and equipped.

How to Tackle Key Challenges in the Promotion of Physical Activity among Older Adults (65+): The AEQUIPA Network Approach

The paper introduces the theoretical framework and methods/instruments used by the Physical Activity and Health Equity: Primary Prevention for Healthy Ageing (AEQUIPA) prevention research network as an interdisciplinary approach to tackle key challenges in the promotion of physical activity among older people (65+). Drawing on the social-ecological model, the AEQUIPA network developed an interdisciplinary methodological design including quantitative/qualitative studies and systematic reviews, while combining expertise from diverse fields: public health, psychology, urban planning, sports sciences, health technology and geriatrics. AEQUIPA tackles key challenges when promoting physical activity (PA) in older adults: tailoring of interventions, fostering community readiness and participation, strengthening intersectoral collaboration, using new technological devices and evaluating intervention generated inequalities. AEQUIPA aims to strengthen the evidence base for age-specific preventive PA interventions and to yield new insights into the explanatory power of individual and contextual factors. Currently, the empirical work is still underway. First experiences indicate that thenetwork has achieved a strong regional linkage with communities, local stakeholders and individuals. However, involving inactive persons and individuals from minority groups remained challenging. A review of existing PA intervention studies among the elderly revealed the potential to assess equity effects. The results will add to the theoretical and methodological discussion on evidence-based age-specific PA interventions and will contribute to the discussion about European and national health targets.

Examples of sex/gender sensitivity in epidemiological research: results of an evaluation of original articles published in JECH 2006-2014

BACKGROUND

During the last decades, sex and gender biases have been identified in various areas of biomedical and public health research, leading to compromised validity of research findings. As a response, methodological requirements were developed but these are rarely translated into research practice. The aim of this study is to provide good practice examples of sex/gender sensitive health research.

METHODS

We conducted a systematic search of research articles published in JECH between 2006 and 2014. An instrument was constructed to evaluate sex/gender sensitivity in four stages of the research process (background, study design, statistical analysis, discussion).

RESULTS

In total, 37 articles covering diverse topics were included. Thereof, 22 were evaluated as good practice example in at least one stage; two articles achieved highest ratings across all stages. Good examples of the background referred to available knowledge on sex/gender differences and sex/gender informed theoretical frameworks. Related to the study design, good examples calculated sample sizes to be able to detect sex/gender differences, selected sex/gender sensitive outcome/exposure indicators, or chose different cut-off values for male and female participants. Good examples of statistical analyses used interaction terms with sex/gender or different shapes of the estimated relationship for men and women. Examples of good discussions interpreted their findings related to social and biological explanatory models or questioned the statistical methods used to detect sex/gender differences.

CONCLUSIONS

The identified good practice examples may inspire researchers to critically reflect on the relevance of sex/gender issues of their studies and help them to translate methodological recommendations of sex/gender sensitivity into research practice.

Searching for sex- and gender-sensitive tuberculosis research in public health: finding a needle in a haystack

Despite broadening consideration of sex- and gender-based issues in health research, when seeking information on how sex and gender contribute to disease contexts for specific health or public health topics, a lack of consistent or systematic use of terminology in health literature means that it remains difficult to identify research with a sex or gender focus. These inconsistencies are driven, in part, by the complexity and terminological inflexibility of the indexing systems for gender- and sex-related terms in public health databases. Compounding the issue are authors’ diverse vocabularies, and in some cases lack of accuracy in defining and using fundamental sex–gender terms in writing, and when establishing keyword lists and search criteria. Considering the specific case of the tuberculosis (TB) prevention and management literature, an analysis of sex and gender sensitivity in three health databases was performed. While there is an expanding literature exploring the roles of both sex and gender in the trajectory and lived experience of TB, we demonstrate the potential to miss relevant research when attempting to retrieve literature using only the search criteria currently available. We, therefore, argue that for good clinical practice to be achieved; there is a need for both public health researchers and users to be better educated in appropriate usage of the terminology associated with sex and gender. In addition, public health database indexers ought to accept the task of developing and implementing adequate definitions of sex and gender terms so as to facilitate access to sex- and gender-related research. These twin advances will allow clinicians to more readily recognize and access knowledge pertaining to systems of redress that respond to gendered risks that compound existing health inequalities in disease management and control, particularly when dealing with already complex diseases. Given the methodological and linguistic challenges presented by the multidimensional and highly contextual nature of definitions of sex and gender, it will be important that this review task be undertaken using a multidisciplinary approach.

Gênero, masculinidades e saúde em revista: a produção da área na revista Saúde e Sociedade

Resumo Este artigo analisa a produção bibliográfica sobre a temática de gênero, masculinidades e saúde publicada na revista Saúde e Sociedade. O método se constituiu de uma revisão bibliográfica de narrativa, de caráter qualitativo, que abrangeu a busca segundo os descritores “gênero” e “masculinidades” em todos os números da revista disponibilizados no sistema Scielo. Foram selecionados 49 resumos de trabalhos para análise descritiva; entre esses, foram analisados em profundidade treze artigos que apresentavam enfoque em homens e mulheres ou que utilizavam apenas homens como sujeitos de análise. A análise narrativa dos artigos e o cotejamento com temas, objetos e perspectivas conceituais do campo da saúde coletiva apontam para a expansão da área de investigação em gênero, masculinidade e saúde, mas também para o caráter incipiente das abordagens conceituais, especialmente quanto à interseccionalidade de gênero e outros marcadores sociais da diferença, como classe social, geração e sexualidade. Esta revisão crítica mostra uma área de pesquisa em expansão, em termos de suas potencialidades e fragilidades.

Meddling with middle modalities: a decomposition approach to mental health inequalities between intersectional gender and economic middle groups in northern Sweden

BACKGROUND

Intersectionality has received increased interest within population health research in recent years, as a concept and framework to understand entangled dimensions of health inequalities, such as gender and socioeconomic inequalities in health. However, little attention has been paid to the intersectional middle groups, referring to those occupying positions of mixed advantage and disadvantage.

OBJECTIVE

This article aimed to 1) examine mental health inequalities between intersectional groups reflecting structural positions of gender and economic affluence and 2) decompose any observed health inequalities, among middle groups, into contributions from experiences and conditions representing processes of privilege and oppression.

DESIGN

Participants (N=25,585) came from the cross-sectional 'Health on Equal Terms' survey covering 16- to 84-year-olds in the four northernmost counties of Sweden. Six intersectional positions were constructed from gender (woman vs. men) and tertiles (low vs. medium vs. high) of disposable income. Mental health was measured through the General Health Questionnaire-12. Explanatory variables covered areas of material conditions, job relations, violence, domestic burden, and healthcare contacts. Analysis of variance (Aim 1) and Blinder-Oaxaca decomposition analysis (Aim 2) were used.

RESULTS

Significant mental health inequalities were found between dominant (high-income women and middle-income men) and subordinate (middle-income women and low-income men) middle groups. The health inequalities between adjacent middle groups were mostly explained by violence (mid-income women vs. men comparison); material conditions (mid- vs. low-income men comparison); and material needs, job relations, and unmet medical needs (high- vs. mid-income women comparison).

CONCLUSIONS

The study suggests complex processes whereby dominant middle groups in the intersectional space of economic affluence and gender can leverage strategic resources to gain mental health advantage relative to subordinate middle groups.

Sex and gender-based analysis in pharmacy practice research: A scoping review

BACKGROUND

Recognizing the potential effect of sex and gender on health outcomes, there is a shift toward conducting sex and gender-based analysis (SGBA) within health research. However, little is known about the extent to which SGBA has been incorporated into pharmacy practice research.

OBJECTIVES

To understand the extent to which SGBA is included in pharmacy practice research.

METHOD

Scoping review of English-language studies identified through MEDLINE, Embase, International Pharmacy Abstracts (IPA), and CINAHL (inception to Jan 2014). Two raters independently screened citations to identify titles and abstracts that included key words related to sex or gender and studies that could be categorized as pharmacy practice research. One author extracted data from included studies related to study design, population, intervention/exposure and outcomes, with results reviewed by another. All authors reviewed eligible articles to categorize them based on a previously-developed typology, and to assess four criteria: 1) the inclusion of sex or gender in research objectives, 2) the depth of sex/gender analysis incorporated into study designs and reporting, 3) the inclusion of sex or gender considerations in interpretation of study results, 4) the intentional and accurate use of sex/gender language.

RESULTS

Of 458 unique search results, only six articles met the inclusion criteria. Two of these six publications included sex/gender considerations in a model consistent with sex/gender based analysis as described by Hammarström. Three of the six studies inaccurately applied sex and gender terminology, whereas the two studies that featured sex or gender in their primary research question did use these terms appropriately.

CONCLUSION

Despite increasing attention on the need for considering sex and gender, there was a paucity of pharmacy practice research publications that conducted SGBA. This presents an opportunity to explore sex, gender and intersectionality when pursuing studies that explore the impact of pharmacists interventions on patient outcomes.

How to study the impact of sex and gender in medical research: a review of resources

There is a growing appreciation by the biomedical community that studying the impact of sex and gender on health, aging, and disease will lead to improvements in human health. Sex- and gender-based comparisons can inform research on disease mechanisms and the development of new therapeutics as well as enhance scientific rigor and reproducibility. This review will assist basic researchers, clinical investigators, as well as epidemiologists, population, and social scientists by providing an annotated bibliography of currently available resource tools on how to consider sex and gender as independent variables in research design and methodology. These resources will assist investigators applying for funding from the National Institutes of Health since all grant applicants will be required (as of January 25, 2016) to address the role of sex as a biological variable in vertebrate animal and human studies.

Integrating and evaluating sex and gender in health research

Both sex (biological factors) and gender (socio-cultural factors) shape health. To produce the best possible health research evidence, it is essential to integrate sex and gender considerations throughout the research process. Despite growing recognition of the importance of these factors, progress towards sex and gender integration as standard practice has been both slow and uneven in health research. In this commentary, we examine the challenges of integrating sex and gender from the research perspective, as well as strategies that can be used by researchers, funders and journal editors to address these challenges. Barriers to the integration of sex and gender in health research include problems with inconsistent terminology, difficulties in applying the concepts of sex and gender, failure to recognise the impact of sex and gender, and challenges with data collection and datasets. We analyse these barriers as strategic points of intervention for improving the integration of sex and gender at all stages of the research process. To assess the relative success of these strategies in any given study, researchers, funders and journal editors would benefit from a tool to evaluate the quality of sex and gender integration in order to establish benchmarks in research excellence. These assessment tools are needed now amidst growing institutional recognition that both sex and gender are necessary elements for advancing the quality and utility of health research evidence.

Justice and Equity Implications of Climate Change Adaptation: A Theoretical Evaluation Framework

Climate change affects human health, and climate change adaptation aims to reduce these risks through infrastructural, behavioral, and technological measures. However, attributing direct human health effects to climate change adaptation is difficult, causing an ethical dilemma between the need for evidence of strategies and their precautionary implementation before such evidence has been generated. In the absence of conclusive evidence for individual adaptation strategies, alternative approaches to the measurement of adaptation effectiveness need to be developed. This article proposes a theoretical framework and a set of guiding questions to assess effects of adaptation strategies on seven domains of health determinants, including social, economic, infrastructure, institutional, community, environmental, and cultural determinants of health. Its focus on advancing gender equity and environmental justice concurrently with the implementation of health-related adaptation could serve as a template for policymakers and researchers.

Access to rehabilitation: patient perceptions of inequalities in access to specialty pain rehabilitation from a gender and intersectional perspective

BACKGROUND

Long-term musculoskeletal pain is common, particularly among women. Pain conditions are a concern in primary health care, and people with severe and complex pain are referred to specialty health care. There is gender bias in access, counselling, assessment, and treatment of long-term pain.

OBJECTIVE

This study explores patient accounts and perceptions about important (social) factors for accessing specialised pain rehabilitation from gender and intersectional equality perspectives. We aimed to identify potential biases and inequalities in accessing rehabilitation resources at a specialised rehabilitation clinic.

DESIGN

Individual semi-structured interviews were conducted with 10 adults after an assessment or completion of a specialised rehabilitation programme in northern Sweden. Qualitative content analysis was used to explore patients' perceptions of important factors for accessing rehabilitation.

RESULTS

One main theme was formulated as Access to rehab - not a given. Three categories of perceived inequality were demonstrated: power of gender, power of social status, and power of diagnosis. Participants perceived rehabilitation as a resource that is not equally available, but dependent on factors such as gender, socio-economic status, ability to work, ethnicity, or age, and more subtle aspects of social status and habitus (e.g. appearance, fitness, and weight). The character of diagnosis received (medical versus psychiatric or social) was also noted.

CONCLUSIONS

It is crucial that professionals are aware of how potential inequalities related to gender, social status, and diagnosis, and their intersections, can be created, perceived, and have influence on the processes of assessment and treatment. Reduction of social determinants of health and biases remain important within global, national, and local contexts.

Changing housework, changing health? A longitudinal analysis of how changes in housework are associated with functional somatic symptoms

AIM

The aim of this study was to analyse how changes in housework over the course of adulthood are related to somatic health in Swedish men and women.

METHODS

Data were drawn from 2 waves of the Northern Swedish Cohort Study, response rate 94.3%, N=1,001. A subsample of cohabiting individuals was selected (n=328 women, 300 men). Outcome variable was functional somatic symptoms (FSS) at age 42. Associations were assessed in multivariate general linear models with adjustment for confounders and somatic health at age 30.

RESULTS

Housework is primarily performed by women, and women's responsibility for and performance of housework increased from ages 30 to 42. These changes were associated with elevated levels of FSS at age 42 in women. Men reported considerably lower responsibility for and performed less housework compared with women, the load of housework for men does not change substantially from ages 30 to 42 and no associations with FSS were identified.

CONCLUSIONS

The gendered division of housework means that women are particularly exposed to a heavy workload. Women's responsibility for and performance of housework increase between ages 30 and 42 and this threatens to be embodied in the form FSS. We conclude that housework should be considered an important source of stress in addition to that from waged work and that a deeper understanding of the links between housework and health requires a gender theoretical analysis.

Developing a Tool for Increasing the Awareness about Gendered and Intersectional Processes in the Clinical Assessment of Patients--A Study of Pain Rehabilitation

OBJECTIVE

There is a need for tools addressing gender inequality in the everyday clinical work in health care. The aim of our paper was to develop a tool for increasing the awareness of gendered and intersectional processes in clinical assessment of patients, based on a study of pain rehabilitation.

METHODS

In the overarching project named "Equal care in rehabilitation" we used multiple methods (both quantitative and qualitative) in five sub studies. With a novel approach we used Grounded Theory in order to synthesize the results from our sub studies, in order to develop the gender equality tool. The gender equality tool described and developed in this article is thus based on results from sub studies about the processes of assessment and selection of patients in pain rehabilitation. Inspired by some questions in earlier tools, we posed open ended questions and inductively searched for findings and concepts relating to gendered and social selection processes in pain rehabilitation, in each of our sub studies. Through this process, the actual gender equality tool was developed as 15 questions about the process of assessing and selecting patients to pain rehabilitation. As a more comprehensive way of understanding the tool, we performed a final step of the GT analyses. Here we synthesized the results of the tool into a comprehensive model with two dimensions in relation to several possible discrimination axes.

RESULTS

The process of assessing and selecting patients was visualized as a funnel, a top down process governed by gendered attitudes, rules and structures. We found that the clinicians judged inner and outer characteristics and status of patients in a gendered and intersectional way in the process of clinical decision-making which thus can be regarded as (potentially) biased with regard to gender, socio-economic status, ethnicity and age.

IMPLICATIONS

The clinical implications of our tool are that the tool can be included in the systematic routine of clinical assessment of patients for both awareness raising and as a base for avoiding gender bias in clinical decision-making. The tool could also be used in team education for health professionals as an instrument for critical reflection on gender bias.

CONCLUSIONS

Thus, tools for clinical assessment can be developed from empirical studies in various clinical settings. However, such a micro-level approach must be understood from a broader societal perspective including gender relations on both the macro- and the meso-level.

Gender inequalities in excess adiposity and anaemia combine in a large double burden of malnutrition gap detrimental to women in an urban area in North Africa

OBJECTIVE

The nutrition transition has exacerbated the gender gap in health in the Middle East and North Africa region as the increase in excess adiposity has been much higher among women than men. This is not exclusive of the persistence of anaemia, generally also more prevalent among women. We assessed the magnitude and sociodemographic factors associated with gender inequality vis-à-vis the double burden of excess adiposity and anaemia.

DESIGN

Cross-sectional study, stratified two-stage cluster sample. BMI (=weight/height2) ≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity. Anaemia was defined as Hb <120 g/l for women, <130 g/l for men. Gender inequalities vis-à-vis the within-subject coexistence of excess adiposity and anaemia were assessed by women v. men relative prevalence ratios (RPR). Their variation with sociodemographic characteristics used models including gender × covariate interactions.

SETTING

Greater Tunis area in 2009-2010.

SUBJECTS

Adults aged 20-49 years (women, n 1689; men, n 930).

RESULTS

Gender inequalities in excess adiposity were high (e.g. overweight: women 64·9 % v. men 48·4 %; RPR=2·1; 95 % CI 1·6, 2·7) and much higher for anaemia (women 38·0 % v. men 7·2 %; RPR=8·2; 95 % CI 5·5, 12·4). They were striking for overweight and anaemia (women 24·1 % v. men 3·4 %; RPR=16·2; 95 % CI 10·3, 25·4). Gender inequalities in overweight adjusted for covariates increased with age but decreased with professional activity and household wealth score; gender inequality in anaemia or overweight and anaemia was more uniformly distributed.

CONCLUSIONS

Women were much more at risk than men, from both over- and undernutrition perspectives. Both the underlying gender-related and sex-linked biological determinants of this remarkable double burden of malnutrition inequality must be addressed to promote gender equity in health.

"A Somali girl is Muslim and does not have premarital sex. Is vaccination really necessary?" A qualitative study into the perceptions of Somali women in the Netherlands about the prevention of cervical cancer

Introduction

Participation in Human Papillomavirus (HPV) vaccination and Papanicolaou Screening (Pap smears) is low among ethnic minorities in the Netherlands and hardly any information is available about the cervical cancer prevention methods of Somali women living in the diaspora. This qualitative study, based on the Health Belief Model (HBM) and an intersectionality-based framework, explores the perceptions of Somali women living in the Netherlands regarding measures to prevent cervical cancer.

Methods

Semi-structured interviews have been conducted with young Somali women aged 17–21 years (n = 14) and Somali mothers aged 30–46 years (n = 6). Two natural group discussions have been conducted with 12 and 14 Somali mothers aged 23–66 years. The collected data has been analyzed thematically for content.

Results

In this study, we have identified perceived barriers to the use of preventive measures across three major themes: (1) Somali women and preventive healthcare; (2) Language, knowledge, and negotiating decisions; and (3) Sexual standards, culture, and religion. Many issues have been identified across these themes, e.g., distrust of the Dutch health care system or being embarrassed to get Pap smears due to Female Genital Mutilation (FGM) and having a Dutch, male practitioner; or a perceived low susceptibility to HPV and cancer because of the religious norms that prohibit sex before marriage.

Conclusions

Current measures in the Netherlands to prevent women from developing cervical cancer hardly reach Somali women because these women perceive these kinds of preventative measures as not personally relevant. Dutch education strategies about cervical cancer deviate from ways of exchanging information within the Somali community.

Teachers can provide culturally sensitive information to young Somali women in schools. For Somali mothers, oral education (e.g., poetry or theater) about the Dutch health care system and men’s roles in HPV transmission may be useful.

An intersectional approach, grounded in the HBM, is recommended to promote equal access to preventive health care for Somali women.

Resilience among old Sami women

There is lack of research on old indigenous women's experiences. The aim of this study was to explore how old women narrate their experiences of wellbeing and lack of wellbeing using the salutogenetic concept of resilience. Interviews from nine old Sami women were analysed according to grounded theory with the following themes identified: contributing to resilience and wellbeing built up from the categories feeling connected, feeling independent and creating meaning; and contributing to lack of lack of resilience and wellbeing built up from the category experiencing lack of connectedness. The old Sami women's narratives showed that they were to a high extent resilient and experienced wellbeing. They felt both connected and independent and they were able to create meaning of being an old Sami woman. Having access to economic and cultural capital were for the old Sami women valuable for experiencing resilience. Lack of resilience was expressed as experiences of discrimination, lack of connectedness and living on the border of the dominant society. Analysis of the Sami women's narratives can give wider perspectives on women's health and deepen the perspectives on human resilience and increase the understanding of minority groups in a multicultural world.

Gender equality and smoking: a theory-driven approach to smoking gender differences in Spain

BACKGROUND

The intersection between gender and class can aid in understanding gender differences in smoking.

AIM

To analyse how changes in gender inequality relate to differences in smoking prevalence by gender, education and birth cohort in Spain over the past five decades (1960-2010).

METHODS

The Gender Inequality Index (GII) was calculated in 5-year intervals from 1960 to 2010. GII ranges from 0 to 1 (1=highest inequality) and encompasses three dimensions: reproductive health, empowerment and labour market. Estimates of female and male smoking prevalence were reconstructed from representative National Health Surveys and stratified by birth cohort and level of education. We calculated female-to-male smoking ratios from 1960 to 2010 stratified by education and birth cohort.

RESULTS

Gender inequality in Spain decreased from 0.65 to 0.09 over the past 50 years. This rapid decline was inversely correlated (r=-0.99) to a rising female-to-male smoking ratio. The youngest birth cohort of the study (born 1980-1990) and women with high education levels had similar smoking prevalences compared with men. Women with high levels of education were also the first to show a reduction in smoking prevalence, compared with less educated women.

CONCLUSIONS

Gender inequality fell significantly in Spain over the past 50 years. This process was accompanied by converging trends in smoking prevalence for men and women. Smoking prevalence patterns varied greatly by birth cohort and education levels. Countries in earlier stages of the tobacco epidemic should consider gender-sensitive tobacco control measures and policies.

Development and evaluation of 'briefing notes' as a novel knowledge translation tool to aid the implementation of sex/gender analysis in systematic reviews: a pilot study

Background

There is increasing recognition of sex/gender differences in health and the importance of identifying differential effects of interventions for men and women. Yet, to whom the research evidence does or does not apply, with regard to sex/gender, is often insufficiently answered. This is also true for systematic reviews which synthesize results of primary studies. A lack of analysis and reporting of evidence on sex/gender raises concerns about the applicability of systematic reviews. To bridge this gap, this pilot study aimed to translate knowledge about sex/gender analysis (SGA) into a user-friendly ‘briefing note’ format and evaluate its potential in aiding the implementation of SGA in systematic reviews.

Methods

Our Sex/Gender Methods Group used an interactive process to translate knowledge about sex/gender into briefing notes, a concise communication tool used by policy and decision makers. The briefing notes were developed in collaboration with three Cochrane Collaboration review groups (HIV/AIDS, Hypertension, and Musculoskeletal) who were also the target knowledge users of the briefing notes. Briefing note development was informed by existing systematic review checklists, literature on sex/gender, in-person and virtual meetings, and consultation with topic experts. Finally, we held a workshop for potential users to evaluate the notes.

Results

Each briefing note provides tailored guidance on considering sex/gender to reviewers who are planning or conducting systematic reviews and includes the rationale for considering sex/gender, with examples specific to each review group’s focus. Review authors found that the briefing notes provided welcome guidance on implementing SGA that was clear and concise, but also identified conceptual and implementation challenges.

Conclusions

Sex/gender briefing notes are a promising knowledge translation tool. By encouraging sex/gender analysis and equity considerations in systematic reviews, the briefing notes can assist systematic reviewers in ensuring the applicability of research evidence, with the goal of improved health outcomes for diverse populations.

Show what you know and deal with stress yourself: a qualitative interview study of medical interns' perceptions of stress and gender

BACKGROUND

Medical students report high stress levels and in particular, the clinical phase is a demanding one. The field of medicine is still described as having a patriarchal culture which favors aspects like a physicians' perceived certainty and rationalism. Also, the Effort-Recovery Model explains stress as coming from a discrepancy between job demands, job control, and perceived work potential. Gendered differences in stress are reported, but not much is known about medical interns' perceptions of how gender plays in relation to stress. The aim of this study is to explore how medical interns experience and cope with stress, as well as how they reflect on the gendered aspects of stress.

METHODS

In order to do this, we have performed a qualitative study. In 2010-2011, semi-structured qualitative interviews were conducted with seventeen medical interns across all three years of the Masters programme (6 male, 11 female) at a Dutch medical school. The interview guide is based on gender theory, the Effort-Recovery Model, and empirical literature. Transcribed interviews have been analyzed thematically.

RESULTS

First, stress mainly evolves from having to prove one's self and show off competencies and motivation ("Show What You Know…"). Second, interns seek own solutions for handling stress because it is not open for discussion (… "And Deal With Stress Yourself"). Patient encounters are a source of pride and satisfaction rather than a source of stress. But interns report having to present themselves as 'professional and self-confident', remaining silent about experiencing stress. Female students are perceived to have more stress and to study harder in order to live up to expectations.

CONCLUSIONS

The implicit message interns hear is to remain silent about insecurities and stress, and, in particular, female students might face disadvantages. Students who feel less able to manifest the 'masculine protest' may benefit from a culture that embraces more collaborative styles, such as having open conversation about stress.