HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 3 © Oxford University Press 2004. All rights reserved.
EDITORIALS |
Why build a health promotion evidence base about gender?
Gender has long been recognized as an important determinant of health service usage, but gender is increasingly important in understanding how women and men experience and respond to health promotion programs and interventions and their outcomes. Gender frameworks are vital for understanding not just the differing effects of the determinants of health on either women or men (Doyal, 1995
; Krieger, 2000), but also how health programs should respond in order to improve health outcomes for either women or men. Much needs to be done to improve the evidence base in health promotion with respect to gender.
Gender, as a determinant of health, refers to inter-related dimensions of biological difference, psychological difference and social experience. Biological sex differences include the better infant survival rates of females, and women's longer life expectancy. With respect to these measures, women do seem to have some biological advantages over men, but any biological advantages that contribute to women's longer life expectancy are cancelled out by their social disadvantages (Doyal, 1995). Psychological gender differences include things like health practices, coping skills and self-concept. While these differences are often understood to be at the heart of gender experience, it is social experiences that primarily create gender difference, through social, economic, cultural and political inequities. Gender is embodied in inequities of health (Krieger, 2000) and these inequities are largely socially determined.
Inequity refers to those inequalities in health that are deemed to be unfair or that stem from some form of injustice (Kawachi et al., 2002), so in this way, health inequities cut across health inequalities. The concept of inequity involves relations of equal and unequal power (political, social and economic), and of justice and injustice. Inequity, perhaps more than inequality, is a concept that asserts the need for public policy-driven solutions. Health, as a state of well-being and opportunity, is determined by inequities and injustices related to social and economic structures more than anything else.
Gender is a relational determinant of health because it alters the way we consider any of the social determinants of health, but the effectiveness of gender as a framework is dependent on how we understand it. Rather than seeing gender used as a political code for maintaining a focus on women, gender can be seen as being used selectively or comprehensively. A selective understanding of gendered health sees that it is a concept that represents analysis of men's and women's health, and of the differences between women's and men's health, in the patterns of use of general practitioners, in the uptake of health messages and personal health practices. The more comprehensive understanding of gendered health incorporates analysis of discrimination and its impact, and of the embodiment of inequities of health whereby differences are largely social determined. Mainstreaming or assimilation of women's health into generalist policies and services facilitates a selective approach to gender, rendering the political dimensions of inequity invisible.
It is when we discuss gender and inequities as social experiences that key issues for health promotion arise; these are particularly issues for women's health. There is a responsibility for anyone, whether decision-makers or advocates, when talking about gender, not to use it selectively, i.e. to only mean biological or psychological differences, but to use it comprehensively—to recognize and take responsibility for the stereotypes, societal expectations, discriminations, power relationships and social and sexual norms that shape so much of women's experience, and the social, cultural and economic environment that shapes women's opportunities. Women's particular health issues, their social position, reduced income and long-term financial security, and their vulnerability to stereotypical attitudes and assumptions about their roles in society, are different to those of men, and are frequently disempowering. Indeed, the 1997 UNDP report [cited by (Astbury and Cabral, 2000)] states that no society treats its women as well as its men. Key areas where inequities persist include women's financial security, reproductive and sexual health, emotional and mental health, violence, and caring.
Gender particularly interacts with socio-economic circumstances (Whitehead and Diderichsen, 1997) that are manifest in women's lower levels of income across the lifespan, and in relatively subordinate positions of power and lower levels of decision-making, whether in political arenas, workplaces or within families. It is because of the evidence provided by these dimensions of gendered experience that we must continue to create a gendered health promotion agenda. Yet we must, as Lesley Doyal (Doyal, 1995) points out, reject crude universalism because gender is only one determinant of health and there are very great differences between and among women and men. The health of many different groups of women and men is differentiated by the inter-relationships between determinants of health, including the social gradient, work, violence, disability and rights.
Consideration of gender is necessary to ensure that health promotion policy implementation does not have a disproportionate and adverse impact on women. Women have sought the rethinking of policy approaches, research and program development from a gender perspective to ensure that they are gender aware and address gender equity issues. For example, gender has been shown to be critical to the organization and delivery of drug and alcohol programs, smoking interventions, and programs against violence and sexual assault.
The determinants of health are increasingly prominent in opening up new, critical approaches to strategic planning to achieve better health. All sectors need not only to understand the determinants of health and illness, but how, in particular, the vulnerable and most disadvantaged people of any society are affected by exposure to adverse determinants. Investment in women's health should be focused on seeking sustainable changes to social and health systems in order to overcome inequities that affect all women, but particularly those populations of women who are most vulnerable.
Upstream health promotion work, using models of health care delivery that are empowering, encourages participation and advocacy. Approaches that are directed at social change and policy are needed to ensure gender is not rendered an invisible determinant. Upstream strategies are much more likely to bring about sustainable change than a continual reliance on midstream and downstream strategies. It is in the field of upstream strategies that women's health services and programs have their authentic place, to ensure that research, policy and practice address the economic, social and cultural obstacles that prevent women from fulfilling their potential. Health promotion's agenda is so much more than merely the ‘absence of disease’, because is it about opportunities and capacities. But in developing the capacity to tackle inequities, work must be targeted more if it is to be effective. Inequity itself is a concept about unfairness and forms of injustice, and gender is a concept that embodies inequity. Therefore, gender is a concept that should be used visibly, responsibly and comprehensively, to recognize and actively tackle gendered health and social inequities. Our advocacy base must ensure that there is the capacity in governments to address gender, to enable targeting gender in public policy solutions, to improve the effectiveness of interventions and to aim to improve the evidence base about gender in health promotion interventions.
REFERENCES
Astbury, J. and Cabral, M. (2000) Women's Mental Health—an Evidence-based Review. World Health Organization, Switzerland Review. World Health Organization, Geneva.
Doyal, L. (1995) What Makes Women Sick: Gender and the Political Economy of Health. Macmillan, Houndmills.
Kawachi, I., Subrimanian, S. and Almeida-Filho, N. (2002) A glossary for health inequalities. Journal of Epidemiology and Community Health, 56, 647.
Krieger, N. (2000) Discrimination and health. In Berkman, L. and Kawachi, I. (eds) Social Epidemiology. Oxford University Press, New York.
Whitehead, M. and Diderichsen, F. (1997) International evidence on social inequalities in health. In Drever, F. and Whitehead, M. (eds) Health Inequalities. Decennial Supplement. The Stationery Office, London (National Statistics Series DS No. 15).
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