Results

COMPARISONS BETWEEN MEN AND WOMEN

Women were younger and showed slightly lower percentages of manual class workers than men (46% v 51%). The prevalence of chronic conditions and poor mental health was significantly higher among women in both social classes, whereas differences were not statistically significant for poor self perceived health status and LLI. There were no gender differences in the health related behaviours. Family demands variables were similar for both gender and classes except for living with children under 15 years, which was more frequent among non-manual female workers. Twenty one per cent of the sample lived in households with more than four members and 11% lived with persons older than 65 years (table 1).

After adjusting for age, gender differences in ill health were statistically significant for the four health indicators analysed and ORs almost did not change when logistic regression models were additionally adjusted for family demands. Among manual workers the magnitude of gender differences in mental health was much higher than among non-manual workers (adjusted OR=2.21; 95%CI=1.68, 2.90 and OR=1.39; 95%CI=1.04, 1.86 respectively). As in the crude analysis, there were no gender differences in leisure time physical activity or in time spent sleeping (table 2).

RELATION BETWEEN FAMILY DEMANDS AND HEALTH OUTCOMES

Factors associated with ill health differed by gender and social class. Among non-manual workers, for both men and women, family demands were not associated with any health indicator. Nevertheless, among manual men, living with children under 15 years (adjusted OR=2.44; 95%CI=1.36, 4.38) or with persons older than 65 years (adjusted OR=1.64; 95%CI=0.90, 2.98) was positively associated with LLI (table3).

Household size had a greater impact in female manual workers' health (table 4). Thus, a significant adverse effect on three of the ill health indicators—self perceived health status, LLI and chronic conditions—was observed. Interestingly there was a consistent gradient. In this group the adjusted ORs associated to living in household units of more than four persons as compared with the referent category were 2.74 (95%CI=1.22, 6.17) for self perceived health status, 3.16 (95%CI=0.98, 10.15) for LLI and 3.28 (95%CI=1.45, 7.44) for having at least one chronic condition. Neither in men nor in women was household size associated to mental health.

Among women, living with children under 15 years was not associated with any health indicator but, unexpectedly, among female manual workers living with persons older than 65 years showed a statistically significant negative association with self perceived health status (adjusted OR=0.33; 95%CI=0.16, 0.66) and having at least one chronic condition (adjusted OR=0.45; 95%CI=0.24, 0.87).

RELATION OF FAMILY DEMANDS WITH LEISURE TIME PHYSICAL ACTIVITY AND TIME SPENT IN SLEEPING

Among men, family demands were not associated with health related behaviours (table 5). However, for women, family demands showed a positive association (table 6). Among manual female workers, no leisure time physical activity was more frequent among those living with children under 15 years (adjusted OR=2.37; 95%CI=1.43, 3.92) and sleeping six hours or less a day was related to household size (the adjusted OR for living in household units of more than four persons was 2.60; 95%CI=1.12, 6.00) and to living with children under 15 years (adjusted OR=1.91; 95%CI=1.13, 3.22). Household size was also positively associated with no leisure time physical activity among female non-manual workers.

Discussion

COMPARISONS BETWEEN MEN AND WOMEN

As in many studies, morbidity, as measured with four health indicators, was higher among women,5-9 28-30 in both manual and non-manual social classes. Moreover, gender health differences were not accounted for by differences in age or family demands. Some studies have not found gender differences in health,2 3 whereas others have found a female excess only for some health indicators.4 31 In the present population there were no gender differences in reported leisure time physical activity or in sleeping six hours or less. These findings are consistent with the results of Bird et al 32 who did not find differences between men and women in the time spent in active leisure time physical activity and in sleeping. However, others have found that men are more likely to be involved in sport activities than women.30 33

These differences in the gender pattern of health and health related behaviours between studies might be accounted for by differences in the cultural settings being analysed or by the specific characteristics of the samples. There is a high heterogeneity among studies in the populations analysed. Most of them have studied general populations with no role restrictions31; others have restricted the populations by age, socioeconomic status or occupation. There is also a high heterogeneity in the health outcomes analysed and, although it has been reported that gender differences in health vary according to the symptom or health condition considered, many studies have focused on only one health indicator.3 34 This lack of a systematic approach makes comparisons between studies difficult, and emphasises the need for increasing efforts directed at the development of theoretical models that are sensitive to social structural dimensions of gender relations if we want to fully understand gender patterns of health and illness.34 35

RELATION BETWEEN FAMILY DEMANDS AND HEALTH OUTCOMES IN MEN AND WOMEN

Family demands had a greater impact on health of female manual workers. Household size had a consistent positive relation with three of the four health indicators. Moreover a consistent gradient was found. Although household size has seldom been used as a measure of family demands, it seems to be a good indicator of total domestic workload for married women, more sensitive, in this study, to women's health than living with children under 15 years. For example, Walters36 observed that stress was more frequent among women in larger households.

Obviously, family demands depend not only on household size, but also on other variables such as the age of children and the number of them in each age strata living at home,8 but these data were not collected in the CHS. Most studies have generally equated domestic responsibilities with children. The evidence about the effect of parenthood on health overall shows that among women children at home decrease psychological well being or have no impact at all.37 Children may improve well being in favourable circumstances including sufficient family income, mother's paid employment, available and affordable child care services, and support from husband or other relatives in the household.38

Among manual female workers living with adults older than 65 years showed an unexpected negative association with three out of four ill health indicators (although the association was not statistically significant for LLI). Walters36 found that stress and anxiety were more frequent among women who reported caring for an elderly or sick relative. In a study of nurses, caring for a dependent adult was a risk factor for women but not for men.29Bartley et al 11 included cohabiting with adults older than 75 years in a combined measure of domestic conditions considering them a priori as a source of workload. However, they pointed out that it was impossible to establish whether co-resident older adults in the household were themselves either receiving care or, as in many cases, providing it. This may be the case in the present study. Nowadays people older than 65 years have few limitations in their daily activities, as compared with some years ago.39 In addition, those living with female workers might have even a better health status than others of the same age, because otherwise women usually have to leave the labour market to take care of them or, if they have enough economic resources, send them to geriatric residences. Thus, it seems probable that the negative association between living with older adults and health among female manual workers may be mediated by the emotional and/or instrumental support they provide (for example they can look after the children at home). Although it is likely that the oldest people had a poor health status, and they might be more a source of work demands than of support, unfortunately additional information on age was not available. Given that the population of elderly is growing rapidly, it would be worthwhile to include more detailed information about the age of people older than 65 living at home in future health surveys.

Recent studies have pointed out the importance of working part time or full time for women's health. Bartley et al 40 observed that while health in women without children was better in full time paid workers as compared with those without paid employment, a tendency for an opposite relation was found for women with children. Full time working mothers had a significantly increased risk for poor health compared with mothers with part time or no paid employment. In another study women with full time and part time paid work were more likely to experience lower levels of physical and psychological symptoms than housewives, but part time work seemed to be more advantageous.11 Although in this study this variable was not available, in 1994 only 15% of female Catalonian workers were in part time jobs.41 This means that most of them had a full time job and they probably had also to assume the majority of domestic tasks.

Family demands were related to men's health only among manual workers in the case of LLI. Living with children under 15 years and with persons older than 65 years were positively associated to LLI (although p=0.1 for living with elderly). More than half of the causes of LLI were musculoskeletal, mainly back pain related. Men's back pain has been associated with young children42 and we may speculate that the association between men's health and living with young children or people older than 65 years could be explained by a division of domestic workload that would assign activities related to the use of physical effort for moving children or disabled old persons to men. To confirm this hypothesis will require further research.

Reporting no leisure time physical activity was positively related to living with children under 15 years among female manual workers. A lack of time is the most commonly cited barrier for participation in physical activity43 and caring for children might mean, not only a lack of time, but also a constraint to autonomy and consequent difficulties for leisure time physical activities among working class married women. Household size and living with children under 15 years were also associated with sleeping six hours or less a day among female manual workers. These results suggest that working class women “finance” the double burden of job and family demands with reductions in their personal time.

One of the issues that has been neglected in the research on gender differences in health is whether they are influenced by social class.35 In this study we have provided some evidence that, although there is a female excess of morbidity both among manual and non-manual workers, the relation between family demands and health does not only depend on gender but also on social class. Family demands are mainly associated with female manual workers' health. This finding can be related both to the interaction between family demands and the psychosocial job characteristics or the material conditions where domestic work is carried out. Lennon et al 44 reported that the degree of control at work (higher among non-manual workers) moderates the effects of demands in the family. On the other hand, women of non-manual social class have higher resources for facing domestic work. Clearyet al 45 found a positive relation between the number of children in the household and depression in women with paid employment but this relation was insignificant after controlling for family income. High income enables paid help with domestic tasks and childcare to relieve working women of some of the overload. Among female manual workers elderly people living at home could assume this role of support for doing domestic tasks. Another interesting aspect to be considered could be how the social class of the spouse influences gender patterns on health but unfortunately this information was not collected in the CHS.

In conclusion, as Emslie et al 31 have noted, many previous studies on gender and health have been based on general population samples but given the strongly gendered nature of contemporary society, comparisons between men and women may be confounded with comparisons between other axes of social differentiation such as employment and domestic roles. Moreover, the effect of family demands may depend on employment and marital status making it necessary to consider multiple interaction terms that could make interpretation of results difficult. These limitations have been reduced in this study with the restriction of the population analysed to those employed and married or cohabiting.

In summary, we have found a female excess in the four ill health indicators analysed—self perceived health status, LLI, having at least one chronic condition and mental health—but no gender differences in reported leisure time physical activity and in sleeping less than six hours a day. We have also shown that among female manual workers, family demands are consistently associated with different ill health indicators and health related behaviours, but there is almost no association with female non-manual worker's or with male's health and health related behaviours. A significant finding was that, in contrast with the expected, living with people older than 65 years had a negative association with some health indicators among female manual workers.

Although we do not know the level of involvement in domestic work among the studied population, in a survey carried out in 1995 in the metropolitan area of Barcelona (Barcelona is the capital of Catalonia), even among women in the workforce, the majority of household tasks continued to be performed by them,46 with more or less resources depending on social class. The work overload, the conflicting demands of paid and unpaid work and the lack of time for themselves, may be some of the factors associated to manual class women's ill health.

When gender differences in health are analysed both the paid and the non-paid work should be considered, as well as the interaction between these two dimensions, gender and social class. Moreover more effort should be devoted to the consideration of the conditions and the psychosocial context of both paid and domestic work for both men and women.10 Many women in Europe choose to work part time when their domestic workload is high. However, part time work has been associated with a higher frequency of negative work characteristics than full time paid work.47 That suggests that part time work does not necessarily provide women with a solution when they attempt to balance work life and home life roles. In Catalonia, as probably in Spain and in other countries, private changes such as sharing domestic responsibilities, as well as active public policies for facilitating family care, taking into account the limitation of resources among women of lower social classes, are needed in order to reduce gender health inequalities attributable to the unequal distribution of family demands.