Gender differences in structural and behavioral determinants of health: an analysis of the social production of health

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Abstract

This paper explores aspects of the social production of health by focussing on the ways in which levels of health are shaped by structures of social inequality and behaviors or ‘lifestyles’. We address two questions: What is the relative importance of the social, structural and behavioral determinants of health? And, are there gender differences in the determinants of health? These questions are explored using multiple regression analyses of data from the 1994 Canadian National Population Health Survey. Two measures of health are used: subjective health status and the Health Utilities Index (a measure of functional health status). By structural determinants we refer to age, family structure, main activity, education, occupation, income and social support. Behavioral determinants include lifestyle factors related to smoking, drinking, weight and physical activity. Findings indicate that the structures of social inequality are the most important determinants of health acting both independently and through their influence on the behavioral determinants of health. There are very real differences in the factors that predict women's and men's health. For women, social structural factors appear to play a more important role in determining health. Being in the highest income category, working full-time and caring for a family and having social support are more important predictors of good health for women than men. Smoking and alcohol consumption are more important determinants of health status for men than women, while body weight and being physically inactive are more important for women than men. Our findings suggest the value of models which include a wide range of structural and behavioral variables and affirm the importance of looking more closely at gender differences in the determinants of health.

Introduction

Inequalities in health have not been as strong a focus in Canada as in countries such as Great Britain. However, there has been increasing recognition and documentation of the social bases of health and this has including an emphasis on inequalities in mortality and morbidity (Canada, 1986; Federal, Provincial, Territorial Working Group on Women's Health, 1990; Evans et al., 1994; Federal, Provincial and Territorial Advisory Committee, 1994; Walters et al., 1995). Income, occupation, sex, age, social support, stress, feelings of control and mastery of the environment and behaviors such as tobacco use, alcohol consumption, diet and physical activity have all been linked with inequalities in health.

There remain several gaps in the literature in Canada and other countries. For example, research within a materialist or structural framework has often followed what Macintyre (1997)calls the ‘hard’ version of this approach which emphasizes occupational class, income and wealth. Less attention is devoted to the ‘soft’ version which would include economic capital as well as working conditions, education and other aspects of social capital. For instance, there has been relatively little exploration of complex models which combine age, gender and socio-economic status with work and home variables. Also, there have been few studies which analyze whether different models predict health among women and men; at best studies have tended to control for sex rather than analyzing the importance of gender. Moreover, we continue to be faced with the problem of interpreting those associations which have been identified. The direction of relationships is at issue and the relative contribution of different influences on health is uncertain. Studies have also suffered from an overemphasis on the generation of data with less attention to the development of theoretical models (Coburn and Eakin, 1993). Similar comments have been directed towards cultural–behavioral models which have tended to focus on individual responsibility and choice rather than exploring the structured contexts which constrain choices (Macintyre, 1997).

Our objective in the research reported here is to explore aspects of the social production of health by focussing on the ways in which levels of health are shaped by structures of social inequality and behaviors or ‘lifestyles’1. We address two questions: What is the relative importance of the social structural and behavioral determinants of health? And, are there gender differences in the determinants of health? We were guided by a model of the social production of health which emphasizes both structural and behavioral influences on health. Our analysis explores the nature and strength of the associations between these variables and measures of health. We were interested in their relative contributions to levels of health. We also investigate the model for men and women separately, to determine whether separate analyses for men and women yield models which are different.

Research in Canada and other countries has revealed relationships between level of health and structures of inequality such as social economic condition, sex, race and age. With respect to social economic condition (measured by income, occupational status, home ownership, access to a car) health differences can be observed throughout the socio economic spectrum (see for example, Townsend and Davidson, 1982; Wilkins and Adams, 1983; Pugh and Moser, 1990; Popay and Jones, 1990; Blaxter, 1990; Arber, 1990, Arber, 1991; Townsend et al., 1992; Adams, 1993; Manga, 1993; Statistics Canada, 1994; Walters et al., 1995; Marmot et al., 1997). Poor health is not simply concentrated among those who are most deprived. Health status declines with each decline in socio economic status and thus it is important to focus on the broader structure of social economic condition rather than on material deprivation alone, though the determinants of health may vary at different levels of socio-economic status (Marmot et al., 1997).

In addition to well documented links between social economic condition and health, research has identified sex differences in health status (Blaxter, 1990; Ferrence, 1993; Statistics Canada, 1994) but the pattern is not as clear and consistent as has often been supposed. It is typically noted that men have a shorter life expectancy, while women report greater morbidity and appear to experience more low level mental health problems. However, recent research by Macintyre et al. (1996)suggests that sex differences in morbidity are more complicated, varying by age and by condition.

Studies which integrate structures of inequalities and gender differences in health are rare, for example whether socio-economic inequalities vary by gender, or whether gender differences vary by socio-economic position. Reviewing the literature, Macintyre and Hunt (1997)demonstrate that socio-economic gradients in health varies by gender, although there are exceptions to the rule such as body size and shape. They argue for further studies on the intersection of gender and structures of socio-economic inequalities.

Age differences in health status have been well documented (Wilkins et al., 1988; Penning and Chappell, 1993; Statistics Canada, 1994; Walters et al., 1995) though, as in the case of sex differences, the patterns of association are complex. Physical health deteriorates with increasing age, while levels of stress diminish and psycho social problems are reported most frequently by those in their 30's and 40's. Important age–sex health differences also exist in chronic health conditions and mental health (D’Arcy, 1987; Beck and Pearson, 1989; Pearson and Beck, 1989) and the way health varies with age is stratified by social economic condition (House et al., 1994).

There is another key literature that traces links between work and health (see for example, LaCroix and Haynes, 1987; Hall, 1989; Lowe, 1989; Karasek and Theorell, 1990; Messing, 1991; Waldron, 1991; Frankenhauser et al., 1991; Barnett et al., 1991; Doyal, 1995). Levels of health are influenced by whether or not people are employed, the degree of job security they enjoy, whether they work full- or part-time, the types of shifts they work, as well as features of the social organization of work such as decision latitude, psychological demands, social support and the opportunity to help others. Research on work and health has been criticized for its emphasis on occupations that are most typically held by men, less attention being devoted to public sector and service jobs in which women are employed and in which the demands and rewards may differ (Barnett et al., 1991; Hall, 1992; Walters et al., 1996, Walters et al., 1997). There is, however, an increasing body of research which is starting to correct the imbalance (Lowe, 1989; Messing, 1991; Messing et al., 1995).

Accompanying the growing emphasis on women in the workplace is an increasing recognition of the links between health and responsibilities in the home (Graham, 1984, Graham, 1993; Rosenberg, 1984; Tierney et al., 1990). Women's unpaid work in the home has been recognized and particularly the stress arising from the double day of work for women who work in the labor force (Lowe, 1989; Walters and Denton, 1997; Walters et al., 1997). On the other hand, isolation within the home is associated with poorer health status (LaCroix and Haynes, 1987; Repetti et al., 1989; Walters et al., 1997; Walters et al., 1995), though full-time work may be less beneficial than part-time employment (Hall, 1992). Also, married women may experience greater benefit from working outside the home (Waldron and Jacobs, 1989). In an effort to understand the complex links between the public sphere of work and the private sphere of the family, more recent research is starting to examine specific features of occupational roles and family responsibilities, including household composition, the burden of domestic responsibilities and caring roles across the generations, availability of day care and assistance with child care. Moreover, rather than focussing on women alone, recent studies have also included men, recognizing that they also have paid and unpaid work roles which may influence their well-being (Barnett and Marshall, 1992, Barnett and Marshall, 1993; Hall, 1992; Hunt and Annandale, 1993; Walters et al., 1996, Walters et al., 1997).

Social support can also have an important influence on health (Brown and Harris, 1978; Cohen and Syme, 1985; Johnson and Hall, 1988; Blaxter, 1990; House et al., 1994; Roxburgh, 1996; Umberson et al., 1996) and studies suggest that the pathways differ by gender (Shye et al., 1995) age (Olsen et al., 1991) and social economic condition (Oakley and Rajan, 1991). In an analysis of the British Health and Lifestyle Survey, Blaxter (1990)found evidence that those with the fewest family, friendship, working and community roles have the poorest psycho social health. The findings over a number of studies in different countries are very similar. Indeed, as House et al. (1994)note, the associations between health and social support are as compelling as those for tobacco use in the mid-1960's.

Each of these sets of variables have been emphasized in structural analyses of the social production of health and illness. In this respect, health is linked with social structures rather than being viewed in more individualistic terms in relation to behavior patterns or what are commonly termed ‘lifestyles’. While the latter may be shaped by broader cultural values, as well as economic interests, they are typically presented as individual choices about tobacco and alcohol consumption, exercise and food. It is such issues that are emphasized in cultural–behavioral explanations of health and illness and there is considerable documentation of the links between tobacco, alcohol, diet, exercise and health (Blaxter, 1990).

In this paper we address two questions which arise from these different theoretical approaches to understanding health. First, what is the relative contribution of structural and behavioral factors to levels of health? The patterns may be complex and highly interwoven. While each factor may have a significant and independent effect on health, their interactions may also play an important role. The hypotheses underlying our analysis are that structures of social inequality are the most important determinants of health acting both independently and through their influence on the behavioral determinants of health, and that determinants of health do not operate in exactly the same way among women and men. Research by Blaxter (1990)has suggested that ‘circumstances’ or structural factors have the most powerful influence on health and that those who are most likely to benefit from healthy lifestyles are the more privileged who already are likely to enjoy better health. Others have argued that patterns of behavior are shaped, in part, by the structural and material features of people's lives (Charles and Walters, 1994). For example, Graham (1994)has argued that women who are most disadvantaged are those who smoke and that this can be interpreted in terms of the structurally generated tensions in their lives. In a review of Canadian research, Greaves (1993)noted a similar pattern and she argues that smoking is one way in which people seek to cope with day-to-day stress. Similarly, research on weight and patterns of eating has argued that they have to be understood in the light of the broader cultural context and structured strains in people's lives (Charles and Kerr, 1986, Charles and Kerr, 1988; DeVault, 1991).

In addition to these aspects of the social production of health, our second broad question asks whether models that predict health and illness vary by sex. Do different features in the lives of men and women influence their physical and mental health? Given the vast literature on the ways in which work and family roles, as well as other features of people's lives are gendered, we would expect to see variations in the social determinants of health for women and men. Recent research suggests that this is so (Hall, 1992; Hunt and Annandale, 1993; Walters et al., 1996Walters et al., 1997). Messing (1995)argues that because gender is a proxy for the differences in the lives of men and women, it is never sufficient to simply control for sex in statistical analyses. Controlling for sex mask gender roles and prohibits a fuller understanding of the nature and influence of gender differences.

Section snippets

Methodology

Data used for this analysis comes from the 1994 National Population Health Survey (NPHS). The purpose of this survey was to measure the health status of Canadians and to expand knowledge of health determinants. The survey contains data on health status, health care utilization, behavioral risk factors, psychosocial factors and demographic and socioeconomic information.

In all provinces except Quebec, the NPHS used the multipurpose sampling methodology developed for the 1994 redesign of the Labor

Characteristics of the sample

Most respondents describe their health as good, very good or excellent. About one-in-ten say their health is fair or poor and this occurs more often for females than males (12.7% vs. 10.0%). Most respondents score above a 0.801 on functional health status (HUI), but the proportion is slightly higher for males then females (86.4% vs. 81.0%). Recall that 1.0 signifies perfect health on the HUI.

Turning to the structural determinants of health, age is presented in five-year age cohorts. There is a

Discussion

The first question we addressed in our analysis concerned the relative influence of social structural and behavioral determinants on health and the second question addressed whether different features in the lives of men and women influence their health. With regards to the former, the data confirm observations in other studies (Blaxter, 1990; Graham, 1994) and suggest that social structural factors are more important than behavioral factors in the determination of health. These findings

Acknowledgements

The authors are grateful to Jason Lian and Sharon Webb for research assistance on the data analysis and preparation of tables. The authors would like to acknowledge the Social Sciences and Humanities Research Council and Health Canada for their generous financial support of this project through funding for the McMaster Research Centre for the Promotion of Women's Health.

References (73)

  • R.C Barnett et al.

    Men's job and partner roles: spillover effects and psychological distress

    Sex Roles

    (1992)
  • R.C Barnett et al.

    Men, family-role quality, job-role quality and physical health

    Health Psychology

    (1993)
  • R.C Barnett et al.

    Physical symptoms and the interplay of work and family roles

    Health Psychology

    (1991)
  • C.M Beck et al.

    Mental health of elderly women

    Journal of Women and Aging

    (1989)
  • Blaxter M., 1990. Health and Lifestyles. Routledge,...
  • Brown, G.W., Harris, T., 1978. Social Origins of Depression. Tavistock,...
  • Canada, 1986. Achieving Health for All: A Framework for Health Promotion Health and Welfare. Ottawa,...
  • N Charles et al.

    Food for feminist thought

    The Sociological Review

    (1986)
  • Charles, N., Kerr, M., 1988. Women, Food and Families. Manchester University Press,...
  • N Charles et al.

    Women's health: women's voices

    Journal of Health and Social Care in the Community

    (1994)
  • D Coburn et al.

    The sociology of health in Canada: first impressions

    Health and Canadian Society

    (1993)
  • Cohen, S., Syme, S.L., 1985. Social Support and Health. Academic Press, New...
  • D’Arcy, C., 1987. Aging and mental health. In: Marshall, V. (Ed.), Aging in Canada: Social Perspectives, 2nd ed....
  • DeVault, M.L., 1991. Feeding the Family: the Social Organization of Caring as Gendered Work. University of Chicago...
  • Doyal, L., 1995. What Makes Women Sick? Gender and the Political Economy of Health. Macmillan,...
  • Evans, R.G., Barer, M.L., Marmor T.R. (Eds.), 1994. Why Are Some People Healthy and Others Not? Aldine de Gruyter, New...
  • Federal, Provincial, Territorial Working Group on Women's Health, 1990. Working Together for Women's Health: a...
  • D Feeny et al.

    Multiattribute health status classification systems: Health Utilities Index

    PharmacoEconomics

    (1995)
  • Ferrence, R., 1993. Sex differences. In: Stephens, T. Fowler Graham, D. (Eds.), Health Canada, Canada's Health...
  • Frankenhauser, M., Lundberg, U., Chesney, M. (Eds.), 1991. Women, Work and Health: Stress and Opportunities. Plenum...
  • Furlong, W., Torrance, G.W., Feeny, D., 1995–1996. Properties of Health Utilities Index: Preliminary Evidence. Quality...
  • Graham, H., 1984. Women, Health and the Family. Wheatsheaf,...
  • Graham, H., 1993. Hardship and Health in Women's Lives Harvester. Wheatsheaf,...
  • Greaves, L., 1993. Background Paper on Women and Tobacco (1987) and Update (1990). Minister of Supply and Services,...
  • E.M Hall

    Gender, work control and stress: a theoretical discussion and an empirical test

    International Journal of Health Services

    (1989)
  • E.M Hall

    Double exposure: the combined impact of the home and work environments on psychosomatic strain in Swedish women and men

    International Journal of Health Services

    (1992)
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