Gender differences in illhealth in Finland: patterns, magnitude and change
Introduction
Health, illness and death have been found to be gendered phenomena in the western societies over a long period of time. As early as in the 17th century, John Graunt observed that women live longer than men in Britain (cit. Nathanson and Lopez, 1987, p. 123). Later, in 1927, Fairfield (cit. Nathanson, 1977, p. 14) summarised the issue of gender differences in illhealth by stating that ``women get sick and men die''. More recent evidence from the 1970s on suggests that men continue to have higher age-specific mortality rates than women, while women show poorer health than men. According to Verbrugge and Wingard (1987), p. 125) ``One sex is `sicker' in the short run, but the other in the long run'' or as the slogan also goes ``Women are sicker, but men die quicker'' (see Lorber, 1997a).
Several studies have shown higher age-specific mortality among men than women (Waldron, 1976, Waldron, 1993; Nathanson, 1977, Nathanson, 1984; Wingard, 1982, Wingard, 1984; Clarke, 1983; Verbrugge, 1985; Nathanson and Lopez, 1987; Hart, 1989; Valkonen, 1989; Macintyre, 1993a, Macintyre, 1993b). Gender differences in mortality have been found to vary by cause of death, the differences being largest for violence and accidents and smaller for mortality from other causes of death (Verbrugge, 1989, Waldron, 1993; Koskinen and Martelin, 1994; Koskinen et al., 1995). Gender differences in mortality are largest from early adulthood until middle age, but are visible throughout the life course (Verbrugge, 1985; Vågerö, 1992; Valkonen et al., 1993; Martelin, 1994). A pervasive widening mortality gap between men and women was observed in the mid-twentieth century. By the 1980s this trend became a mixed one. Among young adults widening trends in the gender mortality gap could still be seen in most countries. However, for older adults in Northern and Western European as well as Northern American countries the gap showed a declining trend over the 1980 (Waldron, 1993).
In contrast to their lower mortality women tend to show higher morbidity according to a number of health indicators, such as long-standing illness, acute illness, medically confirmed disease, perceived health, malaise and symptoms, such as headache (e.g. Nathanson, 1977, Nathanson, 1980; Verbrugge, 1978, Verbrugge, 1985, Verbrugge, 1989; Clarke, 1983; Waldron, 1983; Haavio-Mannila, 1986; Macintyre, 1986; Verbrugge and Wingard, 1987; Blaxter, 1990; Celentano et al., 1990; Lundberg, 1990). Women tend to report more of various chronic and acute conditions, a notable deviation from this pattern being injuries. It has been further suggested that whilst men are less often sick, their conditions are often more severe, including diseases which are among the leading causes of death, for example, cardio-vascular diseases (Verbrugge, 1989; Waldron, 1995). Although it has been shown that men have higher morbidity in the early years of life, higher female morbidity has already emerged by adolescence (Sweeting, 1995). Differences accentuate in midlife and can be found throughout the later life course (Arber, 1993; Rahkonen et al., 1995). That women tend to have particularly poorer psychosocial health than men is likely to hold true for western countries in general (Nathanson, 1977; Wingard, 1984; Verbrugge, 1985, Verbrugge, 1989; Verbrugge and Wingard, 1987; Lahelma et al., 1993; Wyke et al., 1998).
Simultaneous examination of mortality and morbidity shows that the gender difference in the length of life without illhealth, i.e. in `health expectancy', is smaller than the gender difference in the total life expectancy (Sihvonen et al., 1998). The advantage of women living longer than men is partly shadowed by the fact that the proportion with illhealth is higher among women than men.
Health research has frequently overlooked gender differences and even fully omitted one gender, usually women. For example, the Black Report on Inequalities in Health (Townsend and Davidson, 1982) reported almost exclusively on studies of male mortality. Even when women have been included results on men have been discussed and observations on women presented as additional results only, a procedure which has been characterised as `add-women-and-stir' (Andersen, 1983).
More recently, studies on women have sought to clarify specifically female illhealth (e.g. Roberts, 1990; Dahl, 1991; Arber and Lahelma, 1993aArber and Lahelma, 1993b; Macran et al., 1994Macran et al., 1996; Doyal, 1995; Science, 1995). As noted by Rodin and Ickovics (1990)a focus on women's health aims to examine problems which concern exclusively or disproportionately women, such as reproductive health.
Research comparing gender differences in illhealth has been surprisingly rare over the last ten years, despite the fact that it has become ``standard good practice to present and analyse data separately for men and women'' (Macintyre, 1993a, Macintyre, 1993b, p. 57). Still in the 1990s, gender seems to be both present and absent in health research as it was in the 1970s and 1980s (Morgan, 1986): present in the sense of the `standard good practice', but absent because little systematic analysis of gender differences is being made.
The patterning of health by gender needs further examination as suggested by Macintyre et al. (1996), p. 617) (see also Verbrugge, 1985; Rodin and Ickovics, 1990) who ``were struck not by the consistency of female excess in reported illhealth, but the lack of the predicted female excess, and by the complexity and subtlety of the pattern of gender differences across different measures of health and across the life course''. Thus available gender comparative research increasingly questions the common wisdom concerning the gender pattern of health and well-being (see Hraba et al., 1996; Macintyre et al., 1996; Umberson et al., 1996; Lorber, 1997a; Wyke et al., 1998). A number of questions are posed: are gender differences in illhealth really as clear cut as they have been presented to be? What are the determinants of the dissimilarities and similarities? Are they stable over time? Do they vary between countries?
Section snippets
Determinants of gender differences in illhealth
The pathways to health and illness include biological, psychological, behavioural and social determinants (Marmot et al., 1984; Evans and Stoddart, 1994). Gender as a determinant of illhealth is related to all these four domains (Nathanson, 1977; Waldron, 1983; Verbrugge, 1989). As Lorber (1997b), p. 21) has recently put it gender differences in illhealth ``emerge from social interaction and social status, in complex interplay with biology, genetic inheritance, hormones and physiology''. In
Context and purpose of the study
This study analyses the patterning of illhealth by gender in a framework that includes a number of potential social determinants of gender differences in illhealth, such as family status, parental status and friendship relations, socioeconomic status, employment status, region and age.
The analyses are based on two cross-sectional nationwide samples from 1986 and 1994 in Finland. This period has seen the largest increase in unemployment since the Great Depression in the early 1930s. The
Sample
The data were derived from two nationwide ``Surveys on Living Conditions'', conducted by the governmental statistical authorities, Statistics Finland, in 1986 and in 1994 in Finland (Sauli et al., 1989; Ahola et al., 1995). The 1986 and 1994 data were collected by personal interviews; the 1994 data collection made use of portable computers. Identical questions were asked in both surveys. The number of respondents was 12,057 in 1986 and 8,650 in 1994. In 1986 the response rate for both genders
Prevalence data of gender differences
Table 1 presents age-adjusted prevalence percentages by health indicator and gender at both measurement points, 1986 and 1994. Out of a total of sixteen gender comparisons, i.e. eight health indicators at two time points, women showed poorer health in ten comparisons. These were long-standing illness, limiting long-standing illness, mental symptoms, somatic symptoms and disability (measured only for those 50 or above), all at both time points. The female to male ratio varied from 1.07
The patterns and magnitude of gender differences in illhealth
Multivariate logistic regression analyses were then used to study the patterns and magnitude of gender differences, while adjusting for possible confounders, i.e. age, year, region of residence, education, marital status, number of friends, number children and age of youngest child. In Table 2, model 1 shows age-adjusted odds ratios for women's illhealth in relation to men. These odds ratios largely confirm what was shown by prevalence data in Table 1, now summarising information from both
Change in gender differences in illhealth over time
We then tested whether gender differences had changed over time (Table 3). The statistical significance tests for two-way interaction effects between year and gender, adjusting for their main effects (model 1), indicate that there is no evidence for a change over time in age-adjusted gender differences for six health indicators. However, the interaction effects for both mental and somatic symptoms are statistically significant (Table 3, model 1). This implies that age-adjusted gender
Summary and discussion
This study sought to analyse the patterns, magnitude and change over time of gender differences in illhealth. We used nationally representative data on adult Finnish men and women from the 1986 and 1994 Surveys on Living Conditions. The study period was characterised by a steep increase in unemployment rates among both genders.
On the basis of previous studies we expected a gender pattern according to which women's health, as a rule, is poorer than that of men's. However, as a number of scholars
Acknowledgements
We are grateful to Jay Ginn and Elianne Riska for their comments on earlier versions of this paper. This study was supported by grants from the Research Council for Health at the Academy of Finland and the Gyllenberg Foundation.
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