Gender equity in health care in Sweden—Minor improvements since the 1990s

A qualitative study on gender barriers to access cataract surgery in rural Gurugram, Haryana, India

This study aims to comprehend nuances of gender barriers to access cataract surgery in the rural population of Gurugram district, Haryana, India. Data from 100 male and 100 female cataract surgery patients who underwent surgery at the university-affiliated hospital’s department of ophthalmology were examined. Data on the patients’ ages, the better eye’s and operated eye’s visual acuity, the cataract’s maturity at the time of surgery and the type of cataract surgery chosen were examined. Visual impairment was defined when the better eye’s visual acuity was less than 6/18 (0.32). At the time of surgery, women had a serious visual impairment in the better eye and also opted for a less expensive surgery option. In-depth interviews and focus group discussions were planned to understand the attitude, social norms and nuances of women’s accessibility to cataract surgery. This essay includes a qualitative investigation on access restrictions based on gender.

Female gender: A significant barrier to access cataract surgery in rural Gurugram, Haryana, India

The goal of this study is to determine whether the female gender is a barrier for the access to cataract surgery in the rural population of Gurugram district, Haryana, India.

The data of consecutive 100 male and 100 female patients operated for cataract surgery at Department of Ophthalmology, University-affiliated hospital were studied. Data pertaining to age of the patients, visual acuity of the operated and better eye, maturity of the cataract at time of surgery, type of cataract surgery opted were analysed. Visual impairment was considered when visual acuity of the better eye was less than 6/18 (0.32).Two types of cataract surgery were offered to the patients: manual small-incision cataract surgery (SICS) and phacoemulsification. Independent t-tailed test was used to analyse data to ascertain female gender as a barrier to access cataract surgery.

The findings indicate that the difference in age at the time of surgery between men and women was not statistically significant ( p = .327). The analysis of visual impairment in the operated eye of men and women was also not statistically significant ( p = .173). However, the analysis of visual impairment in the better eye was strongly suggestive of gender bias with statistically significant results ( p = .001). In total, 71% male and 56% female patients opted for phacoemulsification surgery, whereas 44% women and 29% men chose less-expensive manual SICS surgery.

The study indicates that females had severe visual impairment in the better eye at the time of surgery and also opted for a less-expensive option indicating less financial freedom and decision-making power.

Regional and sex differences in retinal detachment surgery: Japan-retinal detachment registry report

It is known that social factors affect the choice of treatments, and special attention has been paid to sex differences. The purpose of this study was to determine whether regional and sex differences exist in the treatment of rhegmatogenous retinal detachment (RD). We used Japan-RD Registry database of 2523 patients aged ≥ 40 years between February 2016 and March 2017 in 5 Japanese regions. Regional differences of patients' perioperative factors were analyzed. The factors affecting the proportion of patients who underwent surgery within one week of the onset, defined as early-surgery, were examined by logistic regression. We observed regional differences in perioperative factors, especially in the use of phacovitrectomy, general anesthesia, and air-tamponade, which was higher in certain regions. (Fisher's exact test, all P = 0.012) The proportion of early-surgery was significantly higher among men in Kyushu region (Odds ratio (OR) 1.83; 95% confidence interval (CI) 1.08-3.12; P = 0.02), and it was also significantly higher after adjusting for covariates (OR 1.89; 95% CI 1.06-3.42; P = 0.02). Regional and sex differences exist in the treatment of RD in Japan. Although there was no significant differences in the anatomical outcomes, women in certain regions of Japan are less likely to receive early surgical intervention for RD.

Socioeconomic and physical health status changes after visual impairment in Korea using difference-in-difference estimations

This study analyzed the impact of visual impairment on socioeconomic and physical health status and its heterogeneity by severity of visual impairment. We used nationally representative cohort data based on Korean national health insurance claims (2002–2013), which were extracted for 11,030 persons (2206 visually impaired, 8824 control). This was restructured as monthly data for each person (person-month). Multivariate and ordered logistic regressions were conducted, and the pre-impairment status between the visually impaired and non-visually impaired people was adjusted by difference-in-difference (DiD) estimation. Focusing on medical aid (a public healthcare service assistance program for people who cannot afford health insurance premiums), the DiD estimate showed that the likelihood of receiving aid was higher among visually impaired compared with non-impaired people. Mildly and severely visually impaired people were more likely to be medical aid recipients than their counterparts. The severely visually impaired group was more likely to be unemployed. The visually impaired group were less likely to have no comorbidity. Our findings show that the socioeconomic and physical health status of visually impaired people is more likely to deteriorate than that of their non-visually impaired counterparts following onset of impairment.

Have Policies Tackled Gender Inequalities in Health? A Scoping Review

Gender is recognized as one of the most relevant determinants of health inequalities. This scoping review sought to identify and analyse policies, either implemented or formulated as proposals, which aimed to reduce gender inequalities in health. We searched Medline, Web of Science, and Scielo. Of 2895 records, 91 full text articles were analysed, and 33 papers were included. Of these papers, 22 described the process of formulation, implementation, or evaluation of policies whose aim was to reduce gender inequalities in health; six focused on recommendations, and the remaining five dealt with both issues. Our review showed that the policies aimed at reducing gender inequalities in health, either implemented or formulated as proposals, are scarce. Moreover, despite some success, overall progress has been slow. The studies show failures in design and particularly in the implementation process. We found a lack of awareness and capacity in the policy-making progress, under-financing, bureaucratization, shortage of relevant data, and absence of women’s participation in decision-making. Therefore, an emphasis on the design and implementation of gender-sensitive policies seems essential to advance gender equality in health. This scoping review gathers evidence to support the design of such policies and recommendations that can facilitate their implementation.

The pattern and gender disparity in global burden of age-related macular degeneration

PURPOSE

To explore the trend patterns and gender disparity in global burden of age-related macular degeneration (AMD) by year, age, and socioeconomic status using disability-adjusted life-years (DALYs) from Global Burden of Disease (GBD) study 2017.

METHODS

DALYs and impairment data caused by AMD were extracted from GBD Study 2017. World Bank income level (WBIL) and human development index (HDI) in 2017 were cited as indicators of socioeconomic status. The Gini coefficients and the concentration indexes were calculated to unveil trends in between-country inequality. The association between gender inequality and socioeconomic levels was analyzed by Pearson correlation.

RESULTS

Total age-standardized DALYs of AMD showed a slightly descending pattern in recent years. However, gender disparity has existed since 1990 for almost three decades, with female being more heavily impacted. This pattern became more obvious with aging and varied among different WHO and WBIL regions. Meanwhile, female subjects tended to have higher vision impairments. Gini coefficients of AMD burden increased from 0.423 to 0.448, while the ones of female-to-male ratio fluctuated around 0.11 between 1990 and 2017, with concentration indexes changing from 0.024 to -0.057 and 0.046 to 0.029 respectively. Female-minus-male difference (r = 0.1721, p = 0.0195) and female-to-male ratio (r = 0.2072, p = 0.0048) of age-standardized DALYs rates were positively related to HDI.

CONCLUSIONS

Though global AMD health care is progressing, gender imbalance in disease burden of AMD distribution barely improved. Gender sensitive health policy should be emphasized for the increasing elder population and relieving the higher AMD burden of females.

Association of Sex With the Global Burden of Cataract

Importance

Eye disease burden could help guide health policy making. Differences in cataract burden by sex is a major concern of reducing avoidable blindness caused by cataract.

Objective

To investigate the association of sex with the global burden of cataract by year, age, and socioeconomic status using disability-adjusted life-years (DALYs).

Design, Setting, and Participants

This international, comparative burden-of-disease study extracted the global, regional, and national sex-specific DALY numbers, crude DALY rates, and age-standardized DALY rates caused by cataract by year and age from the Global Burden of Disease Study 2015. The DALY data were collected from January 1, 1990, through December 31, 2015, for ever 5 years. The human development index (HDI) in 2015 was extracted as an indicator of national socioeconomic status from the Human Development Report.

Main Outcomes and Measures

Comparisons of sex-specific DALY estimates due to cataract by year, age, and socioeconomic status at the global level. Paired Wilcoxon signed rank test, Pearson correlation, and linear regression analyses were performed to evaluate the socioeconomic-associated sex differences in cataract burden.

Results

Differences in rates of cataract by sex were similar between 1990 and 2015, with age-standardized DALY rates of 54.5 among men vs 65.0 among women in 1990 and 52.3 among men vs 67.0 among women in 2015. Women had higher rates than men of the same age, and sexual differences increased with age. Paired Wilcoxon signed rank test revealed that age-standardized DALY rates among women were higher than those among men for each HDI-based country group (z range, -4.236 to -6.093; P < .001). The difference (female minus male) in age-standardized DALY rates (r = -0.610 [P < .001]; standardized β = -0.610 [P < .001]) and the female to male age-standardized DALY rate ratios (r = -0.180 [P = .02]; standardized β = -0.180 [P = .02]) were inversely correlated with HDI.

Conclusions and Relevance

Although global cataract health care is progressing, sexual differences in cataract burden showed little improvement in the past few decades. Worldwide, women have a higher cataract burden than men. Older age and lower socioeconomic status are associated with greater differences in rates of cataract by sex. Our findings may enhance public awareness of sexual differences in global cataract burden and emphasize the importance of making sex-sensitive health policy to manage global vision loss caused by cataract.

Access for all? Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden

BACKGROUND

Previous studies in Sweden have detected socioeconomic inequities in access to healthcare services. However, there is limited information regarding access in younger populations. The aim of this study was to explore vertical and horizontal inequities in access to healthcare services in young adults in the north of Sweden.

METHODS

The study used data from the Health on Equal Terms survey (age group 16-24 years, n = 2726) for the health and healthcare variables and from national registers for the sociodemographic characteristics. Self-rated healthcare utilization was measured as visits to general practitioners, youth clinics and nurses. Crude and multivariable binomial regression analysis, stratified by sex, was used to assess vertical equity, adjusting for sociodemographic characteristics, and horizontal equity, adjusting for need variables.

RESULTS

Vertical inequity was detected for all three healthcare services (youth clinics, general practitioners and nurses), with variations for men and women. Horizontal inequities were also found for both men and women in relation to all three healthcare services.

CONCLUSIONS

These findings suggest that both vertical and horizontal inequities in access exist for young people in northern Sweden and that the associations between sociodemographic characteristics and healthcare utilization are complex and need further investigation.

Epidemiology of C2 Fractures in the 21st Century: A National Registry Cohort Study of 6,370 Patients from 1997 to 2014

OBJECTIVE

C2 fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. This study aims to investigate the incidence and treatment trend of C2 fractures in Sweden.

METHODS

Patients with the principal and secondary diagnosis of fracture of the second vertebrae (ICD-10: S12.1) between 1997 and 2014 were identified in the Swedish National Patient Registry (NPR).

RESULTS

Between 1997 and 2014, 6,370 patients with a C2 fracture (51% male; age: 72 ± 18) were identified in the NPR. The incidence of C2 fractures increased from 3 to 6 per 100,000 (r = 0.94; p < 0.01), mainly due to an increase of incidence in the geriatric subgroup (≥70 years). The percentage of surgically treated patients decreased from 1997 to 2014 (r = -0.80; p < 0.01). Younger age, male gender, spinal cord injury, and earlier year of admission were associated with surgical treatment assignment.

DISCUSSION

This study documents a rising incidence of C2 fractures in the elderly during the last two decades in Sweden. Greater awareness of fractures, improved diagnostics, coding, and a higher activity level of the patients are plausible causes. The declining trend of surgical treatment warrants further study.

Unintended Consequences of Gender Equality Promotion in Swedish Multicultural Contraceptive Counseling: A Discourse Analysis

In this article, we explore how reproductive health care providers in Sweden, a country often described as one of the most gender-equal countries in the world, incorporate gender equality ideals in multicultural contraceptive counseling. In the tension between gender equality promotion on one hand and respect for cultural diversity and individualized care on the other, we will demonstrate that values of gender equality were often given priority. This is not necessarily undesirable. Nevertheless, our proposal is that the gender equality ideology may inhibit providers' ability to think differently about issues at stake in contraceptive counseling, which may negatively influence women's possibilities to obtain adequate support. At the end of the article, we suggest how health care providers' reflexivity might be used as a working tool for increased awareness about the taken-for-granted cultural norms that exist in their clinical milieu.

Utilization of triptans in Sweden; analyses of over the counter and prescription sales

PURPOSE

To enable easier access to triptans, the drug of choice for moderate to severe migraine, some countries have made triptans available without prescription, that is, over the counter (OTC). Concern has been raised about this. The aim of this study was to describe the utilization pattern of triptans in Sweden before and after the OTC switch.

METHODS

Wholesaler and aggregated sales data from all Swedish pharmacies 1991 to 2011 and patient identity data on dispensed prescriptions 2007 and 2011 from the Swedish National Prescribed Drug Register were used to investigate volume and expenditure of triptans. The databases contain complete data for all drugs sold in Sweden or dispensed to all Swedish inhabitants (9.5 million in 2012).

RESULTS

Volumes of triptans have increased to 7.0 million defined daily doses (DDD) on prescriptions and 0.7 million DDDs OTC in 2011. Prescriptions were dispensed to 10.0 and 10.1 per 1000 inhabitants in 2007 and 2011, respectively. Although half of those dispensed triptans in 2007 were not in 2011, the incidence remained stable at 2.8 patients per thousand person-years. In 2011, the 10% of the heaviest users accounted for 44% and 48% of dispensed triptans in women and men, respectively.

CONCLUSIONS

Triptans OTC and the volumes dispensed on prescription have increased as has the DDD per patient purchasing triptans on prescription. However, the number of patient's dispensed triptans on prescription has remained stable. A concern is that almost half of prescribed triptans are purchased by 10% of the users.

Scouting for talent: appointment practices of women professors in academic medicine

This paper contributes to current literature on the under-representation of women in academic medicine by critically examining appointment practices for medical professors in the Netherlands. By opening the black box of these highly secretive appointments, it is shown how allegedly gender-neutral practices contribute to the perpetuation of gender inequalities in academic medicine. The methods employed include quantitative analysis of 286 appointment reports and qualitative interviews with 21 scouts. The analysis revealed a dominant pattern of recruitment by invitation by male scouts, leading to three gender mechanisms of inclusion and exclusion through formal/informal networking. When candidates are recruited through homogeneous male networks, the pool of potential candidates is drastically restricted. Women are not seen as obvious choices for professorships since their commitment to the job is questioned. Furthermore, women do not correspond to the image of the ideal manager since they do not appear to conform to the gendered preconceptions of leadership held by the predominantly male scouts.

"The Laundry Bag Project"--unequal distribution of dermatological healthcare resources for male and female psoriatic patients in Sweden

BACKGROUND

Psoriasis and eczema are common dermatological diseases that occur with approximately equal frequency in men and in women. The aim of this study was to determine whether men and women with dermatological diseases in need of ultra-violet radiation (UV) treatment receive equal care.

METHODS

We conducted a retrospective analysis of records of all patients referred to and seen at our clinic during 2003 with diagnoses of psoriasis or eczema. We performed a gender-based analysis of the number, type, and estimated cost of the treatments given to each patient. We evaluated similar data from a Swedish Psoriasis Association (SPA) treatment center and from the state pharmacy monopoly (Apoteksstatistiken).

RESULTS

Men with eczema or psoriasis received more help with emollients than did women and were given a greater number of UV treatments. At our clinic and at the SPA center, women constituted 37 and 42%, respectively, of the individuals who received UV treatment; yet, they received only 34 and 36% of the treatments, respectively. Women were prescribed self-care more often than men, with 61% of prescriptions for emollients and 48% of specific topical treatments for psoriasis dispensed to women.

CONCLUSIONS

We discovered previously unrecognized gender differences in standard dermatological treatment for common diagnoses at our hospital. To ensure optimal care for each patient, treatment disparity should be recognized and gender-based analyzes be carried out when planning dermatological health care.

Targeted intervention for the ultra poor in rural Bangladesh: Does it make any difference in their health-seeking behaviour?

It is now well recognised that regular microcredit intervention is not enough to effectively reach the ultra poor in rural Bangladesh, in fact it actively excludes them for structural reasons. A grants-based integrated intervention was developed (with health inputs to mitigate the income-erosion effect of illness) to examine whether such a targeted intervention could change the health-seeking behaviour of the ultra-poor towards greater use of health services and "formal allopathic" providers during illness, besides improving their poverty status and capacity for health expenditure. The study was carried out in three northern districts of Bangladesh with high density of ultra poor households, using a pre-test/post-test control group design. A pre-intervention baseline (2189 interventions and 2134 controls) survey was undertaken in 2002 followed by an intervention (of 18 months duration) and a post-intervention follow-up survey of the same households in 2004. Structured interviews were conducted to elicit information on health-seeking behaviour of household members. Findings reveal an overall change in health-seeking behaviour in the study population, but the intervention reduced self-care by 7 percentage units and increased formal allopathic care by 9 percentage units. The intervention increased the proportion of non-deficit households by 43 percentage units, as well as the capacity to spend more than Tk. 25 for treatment of illness during the reference period by 11 percentage units. Higher health expenditure and time (pre- to -post-intervention period) was associated with increased use of health care from formal allopathic providers. However, gender differences in health-seeking and health-expenditure disfavouring women were also noted. The programmatic implications of these findings are discussed in the context of improving the ability of health systems to reach the ultra poor.