1

TheinfluenceofgenderequalitypoliciesongenderinequalitiesinhealthinEurope

LaiaPalència1,2,3

,DavideMalmusi1,2,3

,DeborahDeMoortel4,LucíaArtazcoz

1,2,3,5,Mona

Backhans6,7,ChristopheVanroelen

4,8,CarmeBorrell

1,2,3,5

1-CIBERdeEpidemiologíaySaludPública(CIBERESP),Madrid,Spain

2-HealthInformationSystemsUnit,AgènciadeSalutPúblicadeBarcelona,Barcelona,Spain

3-Institutd'InvestigacióBiomèdicaSantPau(IIBSantPau),Barcelona,Spain

4-InterfaceDemography,DepartmentofSociology,VrijeUniversiteitBrussel,Belgium

5-DepartmentofExperimentalandHealthSciences,UniversitatPompeuFabra,Barcelona,

Spain

6-DepartmentofPublicHealthSciences,KarolinskaInstitutet,Stockholm,Sweden

7-CentreforEpidemiologyandCommunityHealth,Stockholmcountycouncil,Solna,Sweden

8-HealthInequalitiesResearchGroup(GREDS),UniversitatPompeuFabra,Barcelona,Spain

Addressforcorrespondence:CarmeBorrell

AgènciadeSalutPúblicadeBarcelona

PlaçaLesseps108023Barcelona;Spain

Tel:34-93-2027771;Fax:34-93-3686943

e-mail:cborrell@aspb.cat

Publishedon:SocialScience&Medicine;Volume117,September2014,Pages25–33

http://www.sciencedirect.com/science/article/pii/S027795361400447XAcknowledgements

ThisresearchwassupportedbytheEuropeanCommunity’sSeventhFramework

Programme(FP7/2007–2013,grantagreement278173):“Evaluatingtheimpactof

structuralpoliciesonhealthinequalitiesandtheirsocialdeterminantsandfostering

change(Sophie)”project;bythePlanNacionaldeInvestigaciónCientífica,Desarrolloe

InnovaciónTecnológica(I+D+I)andtheInstitutodeSaludCarlosIII-Subdirección

GeneraldeEvaluaciónyFomentodelaInvestigación(grantPI12/03114);andbythe

programIntensificacióndelaActividadInvestigadora(grantedtoCarmeBorrell)

fundedbytheInstitutodeSaludCarlosIIIandbytheDepartamentdeSalut,

GeneralitatdeCatalunya.

2

ABSTRACT

Fewstudieshaveaddressedtheeffectofgenderpoliciesonwomen’shealthand

genderinequalitiesinhealth.Thisstudyaimstoanalysetherelationshipbetweenthe

orientationofpublicgenderequalitypoliciesandgenderinequalitiesinhealthin

Europeancountries,andwhetherthisrelationshipismediatedbygenderequalityat

countrylevelorbyotherindividualsocialdeterminantsofhealth.

Amultilevelcross-sectionalstudywasperformedusingindividual-leveldataextracted

fromtheEuropeanSocialSurvey2010.Thestudysampleconsistedof23,782menand

28,655womenfrom26Europeancountries.Thedependentvariablewasself-

perceivedhealth.Individualindependentvariablesweregender,age,immigrant

status,educationallevel,partnerstatusandemploymentstatus.Themaincontextual

independentvariablewasamodificationofKorpi’stypologyoffamilypolicymodels

(Dual-earner,Traditional-Central,Traditional-Southern,Market-orientedand

Contradictory).OthercontextualvariablesweretheGenderEmpowermentMeasure

(GEM),tomeasurecountry-levelgenderequality,andtheGrossDomesticProduct

(GDP).Foreachcountryandcountrytypologytheprevalenceoffair/poorhealthby

genderwascalculatedandprevalenceratios(PR,womencomparedtomen)and95%

confidenceintervals(CI)werecomputed.MultilevelrobustPoissonregressionmodels

werefitted.

Womenhadpoorerself-perceivedhealththanmenincountrieswithtraditionalfamily

policies(PR=1.13,95%CI:1.07-1.21inTraditional-CentralandPR=1.27,95%CI:1.19-

1.35inTraditional-Southern)andinContradictorycountries(PR=1.08,95%CI:1.05-

1.11).Inmultilevelmodels,onlygenderinequalitiesinTraditional-Southerncountries

weresignificantlyhigherthanthoseinDual-earnercountries.

Genderinequalitiesinself-perceivedhealthwerehigher,womenreportingworseself-

perceivedhealththanmen,incountrieswithfamilypoliciesthatwerelessorientedto

genderequality(especiallyintheTraditional-Southerncountry-group).Thiswas

partiallyexplainedbygenderinequalitiesintheindividualsocialdeterminantsof

healthbutnotbyGEMorGDP.

Keywords:genderpolicies,genderequality,self-perceivedhealth,Europe

3

INTRODUCTION

Genderinequalitiesaredifferencesbetweenmenandwomenthatsystematically

empoweronegroup(men)tothedetrimentoftheother(women).Intermsofhealth,

itiswellknownthatinindustrializedcountrieswomenlivelongerthanmen,butthey

oftendoitinworsehealth(Annandale&Hunt,2000;Espelt,etal.,2010).Gender

inequalitiesinhealtharisebecauseofinequalitiesinpower,statusandfinancial

resources(Arber&Khlat,2002)aswellasofthesexualdivisionofwork(Malmusi,et

al.,2012).

Genderinequalitiesinhealthareforthemostpartsociallyproduced,andassuchthey

canbeamelioratedthroughchangesinthegenderorder(Annandale&Hunt,2000).

Genderequalitypoliciesrefertothosepoliciespromotingequalitybetweenmenand

women,includingfamilypolicies(whichseektoincreasefamilywellbeingandpromote

reconciliationbetweenpaidworkandfamily),butalsootherssuchaspolicies

promotingequalopportunitiesinthelabourmarketorequalpoliticalrepresentation

(Borrell,etal.,2014).Thesepoliciesimpactgenderinequalitiesinhealththroughtheir

effectonsocialdeterminantsofhealth,suchasthedistributionofpower,income,paid

andunpaidwork,andmoreproximalpathwayssuchasdiscrimination,violence,

financialhardshiportimepressure.Consequently,gender-equalitypoliciesatthe

countrylevelareassumedtoaffectgenderinequalities.However,fewstudieshave

investigatedtheeffectoftheorientationofgenderpoliciesonwomen’shealthoron

genderinequalitiesinhealth(Borrell,etal.,2014).

Agenderpolicyregimeissaidtoentailalogicbasedontherulesandnormsabout

genderrelationsthatinfluencestheconstructionofpolicies(Sainsbury,1999).The

majorityofgenderpolicytypologiesproposedsofarhavebeenbaseduponcriticisms

toEsping-Andersen’s(Esping-Andersen,1990)“genderblind”classificationofwelfare

states(Sainsbury,1999).Korpi,etal.(2013)haveclassifiedcountriesintermsof

dimensionsoftheirfamilypoliciesthataffectthesituationofwomenwithrespect

topaidandunpaidwork.Thesefamilypolicymodelsarethereforebasedontheextent

4

ofsexualdivisionofworktheyarepromotingandconstituteasummaryorproxy

measurefortheconfigurationofgenderequalitypoliciesinagivencountryorgroupof

countries.Somepolicymodelsaresupportiveofthetraditionalfamilymodel,with

menasbreadwinnersandwomenascaregivers,resultinginmorepublicsupporttothe

care-givingroleoffamilies,andabiggerorsmallerroleforthemarketinproviding

care.Otherpolicymodelsaremoresupportiveofthedual-earnermodel,whichrelies

toagreatextentontheprovisionofpublicservicesforcare,inturn,makingwomen

moreindependentfromtheirfamily.ThismodelismainlyrepresentedbytheNordic

countries,whichareusuallybetter-offintermsofgenderequitythantheothers.A

recentreviewhaspartiallysupportedthethesisthatintheNordiccountriesthe

socioeconomicpositionofwomenisbetterandgenderinequalitiesinhealthare

smaller,althoughtheneedforfurtherstudieswashighlighted(Borrell,etal.,2014).

In recent decades, there has also been an interest inmeasuring gender equality at

country level and several indices summarizing the complexity of different gender

equalityindicatorshavebeendeveloped.ExamplesofthesearetheGenderInequality

Index -http://hdr.undp.org/en/statistics/gii/-, theGender-relatedDevelopment Index

and the Gender Empowerment Measure -http://hdr.undp.org/en/-, the Gender

Equality Index -http://eige.europa.eu/content/gender-equality-index- or the Gender

Gap Index -http://www.weforum.org/issues/global-gender-gap-). Most of these

indices include health-related indicators, so correlating them with inequalities in

healthcouldberedundant.Anindexthatdoesnotcontainanyhealthindicatoristhe

GenderEmpowermentMeasure(GEM)(UNDP,2009),whichisameasureofwomen’s

agency based on their participation and decision-making power in the political and

economicspheresandpowerovereconomicresources.

Recently,somestudieshavelookedattheeffectofgenderequalityatthecountry

levelongenderinequalitiesinhealth(Dahlin&Härkönen,2013;VandeVelde,etal.,

2013;VanTuyckom,etal.,2013;Wells,etal.,2012)andonehasconsideredtheeffect

oftheorientationofgenderpoliciesongendergapsinmortality(Backhans,etal.,

2012).AsinthestudybyBackhansetal.,wetakeintoaccountbothapolicytypology

andagenderequalityindicator,althoughinthepresentstudywefocusonself-

5

perceivedhealth,whichisanindicatorgenerallyshowingwomentobedisadvantaged

comparedtomen.Moreover,thepresentstudynotonlyconsidersawiderrangeof

Europeancountries,includingsomeofEasternEurope,butalsothepotentialinfluence

ofindividual-levelsocialdeterminantsofhealth(bothasmediatorsandeffect

modifiers).Thus,theaimofthisstudyistogenerateevidenceontherelationship

betweentheorientationofpublicgenderequalitypoliciesandgenderinequalitiesin

healthinEuropeancountries,andtodeterminewhetherthisrelationshipismediated

bygenderequalityatcountrylevelorbyotherindividualsocialdeterminantsofhealth.

Ourhypothesisisthatcountrieswithmoreequitablegenderpolicieswillachievemore

equalityinhealth,becauseofthehighergenderequalityatboththecountryleveland

thelevelofindividualsocialdeterminantsofhealthsuchaseducationallevel,

employmentstatusorincome.

METHODS

Design,studypopulationandinformationsources

Amultilevelcross-sectionalstudywasperformed,usingindividual-leveldataonhealth,

genderandothersocialdeterminantsofhealth,andcountry-leveldataonfamilypolicy

modelsandGEMastheindicatorofgenderequality.Individualdatawasobtained

fromthe5throundoftheEuropeanSocialSurvey(2010).Thisisanacademically

drivencross-nationalsurveythatusesrepresentativesamplesofallpersonsaged15

andoverresidinginprivatehouseholdsinEuropeancountries

(http://www.europeansocialsurvey.org).Inthisstudyweuseddatafrom26countries

(Belgium,Bulgaria,Switzerland,Cyprus,CzechRepublic,Germany,Denmark,Estonia,

Spain,Finland,France,UnitedKingdom,Greece,Croatia,Hungary,Ireland,Lithuania,

Netherlands,Norway,Poland,Portugal,RussianFederation,Sweden,Slovenia,Slovakia

andUkraine).Individualdatawasavailableforanadditionalcountry(Israel),butwhich

didnotenterthestudyasnoneoftheclassificationsoffamilypolicyregimesincluded

it.Responseratesinthecountriesrangedfrom30.5%inGermanyto81.4%inBulgaria.

Finally,thestudysampleconsistedof23,782menand28,655women.

6

Variables

Ourdependentvariablewasself-perceivedhealthmeasuredthroughthequestion:

“Howisyourhealthingeneral?Wouldyousayitisverygood,good,fair,bad,or,very

bad?”.Theanswerwasdichotomisedintogood(verygood,good)andpoor(fair,bad,

verybad)(Manor,etal.,2000).

Ourmainindependentvariablewasgendermeasuredasmanorwoman.Other

individualsocialdeterminantsofhealthusedwere:A)age,usedbothasacontinuous

variableforstandardisationandadjustmentandasacategoricalvariablefor

stratification(15-19,20-34,35-49,50-64,65+).B)Beinganimmigrantfromacountry

otherthananadvancedeconomyusingthedefinitionoftheInternationalMonetary

Fund(2013).Althoughthisvariablemaynotbeanimportantdeterminantofgender

inequalitiesinhealthitwasimportantforustoconsidertheintersectionsbetween

differentaxesofinequality.C)Educationallevel,measuredbytheInternational

StandardClassificationofEducation(ISCED),whichwemergedinto‘uptolower

secondaryeducation’(ISCED0,1or2),‘uppersecondaryandpost-secondarynon-

tertiaryeducation’(ISCED3,4or5)and‘tertiaryeducation’(ISCED6,7or8).D)

Partnerstatus,classifiedas:nevermarried;separated,divorcedorwidowed;

cohabitingbutnotmarried;ormarried.E)Employmentstatus:forthoseonpaidwork

occupationswereclassifiedasprofessional,servicesandmanualwork,usingthe

InternationalClassificationofOccupationsISCO-88.Otherstatusesoutofemployment

were:student,unemployed,disabledorretired,doinghouseworkorlookingafter

childrenorotherpersons(named“housework”inthetables),andothers.

Ourmainindependentvariableatthecontextuallevel,usedasaproxyfortypologies

ofcountrieswithdifferentgenderequalitypolicies,wasthetypologyoffamilypolicy

modelsinitiallydevelopedbyKorpi(2000),whichhasbeenrevisedrecently(Korpi

2010;Korpi,etal.,2013).Asstatedabove,thesefamilypolicytypologiesare

multidimensionalandareembeddedinawidersocialcontext,andtheyareusefulto

assesstheimpactofdifferentpoliciesonthesituationofmenandwomenin

employmentandalsoothereconomicoutcomes.Moreover,Korpi’sframework

7

encompassesmanymoreEuropeancountriesthanotherexistingclassifications.Korpi

classifiedcountriesin3groups(Box1).ThefirstgroupconsistsofcountrieswithDual-

earnersupport,whicharecharacterisedbypolicyinstitutionsthatencouragewomen’s

continuouslabourforceparticipationandattempttoredistributecaringworkwithin

thefamily(Nordiccountries).ThesecondgroupiscountrieswithTraditionalfamily

policies,presumingthatwomenhavetheprimaryresponsibilityforcareathome.In

thesecountrieswomenenterpaidworkprimarilyassecondaryearners,whilecare

withinfamiliesissubsidizedbythestate(continentalEurope).AthirdgroupisMarket-

orientedcountries,characterizedbyastrongbreadwinnermodelinwhichthemarket

istheprincipalinstitutiongoverningindividuals’andfamilies’accesstoresources.

Korpi’sthreemaincategoriesweresubsequentlyexpandedthroughafourthanda

fifthmodel.Thefourthmodel,whichsimultaneouslyattemptstobothpreservehighly

gendereddivisionsoflabourandsupportforthedual-earnerfamily,hasbeenlabeled

“Contradictory”andismostclearlyrepresentedbyEasternEuropeanorTransition

countries(Boye,2011;Ferrarini&Sjoberg,2010).Finally,becausethesetofcountries

incontinentalEuropeisveryheterogeneousintermsofgenderpolicies,wehave

createdanewcategorywithallSouthernEuropeancountries(Traditional-Southern)

separatingthemfromothercontinentalcountrieswhicharenamedTraditional-

Central.Thecreationofsuchanadditionalcategoryforfamilypolicieshadalready

beensuggestedinearlierresearch(Thévenon,2011).

AdditionalindependentvariablesatthecontextuallevelaretheGEMof2009,which

attemptstomeasuretheextentofgenderinequalityacrosscountriesbasedonthe

proportionofseatsheldbywomeninnationalparliaments,percentageofwomenin

economicdecisionmakingpositionsandfemaleshareofincome(UNDP,2009).The

GrossDomesticProduct(GDP)of2010(WorldBank)wasusedasaconfounding

variableasgenderequalityscoresusuallytendtobehigherinmoreeconomically

advancedcountries.

Analyses

8

Weightsderivedfromthesampledesignwereusedinallcalculations.Severalofthe

sampledesignsusedbycountriesparticipatingintheEuropeanSocialSurveywerenot

completelyrandom.Thedesignweightcorrectsfortheseslightlydifferentprobabilities

ofselection,therebymakingthesamplemorerepresentativeofa‘true’populationof

individualsaged15andoverineachcountry.

Age-standardisedprevalence(using10-yearagegroupsandstandardisedbythedirect

method(Rué&Borrell,1993)beingthetotalsampleweightedbycountrythe

referencepopulation)ofpoorself-perceivedhealthwascalculatedbygenderforeach

countryandtypology.Prevalenceratios(PR)ofpoorself-perceivedhealthinwomen

comparedtomenwerecalculatedbyfittingPoissonregressionmodelswithrobust

variance(Zou,2004)adjustedbyageineachcountryandineachcountrytypology(in

thiscasealsoadjustingbycountry).Ineachcountrytypology,PRofpoorself-perceived

healthinwomencomparedtomenwerealsocalculatedstratifyingbyeachsocial

determinantofhealthconsidered.Finally,todetermineifgenderinequalitiesvaried

accordingtocountrytypology,multilevel(Diez-Roux,2000)robustPoissonregression

modelswerefitted.Amodelwithrandominterceptandgenderslope,includingthe

typologyasapredictorofthegenderslopewasconductedtoseeifgenderinequalities

variedbycountrytypologygroup(model1).Thismodelwassubsequentlyaugmented

byaddingindividualvariables(model2),thenGEM(model3)andthenGDP(model4)

aspredictorsofthegenderslopetodetermineifthesevariablesmediatedtheeffectof

thecountrytypologyongenderinequalitiesinself-perceivedhealth.

AllanalyseswereperformedusingStata11.2forWindows,exceptthemultilevel

analyseswhichwereperformedusingHLM6.02.

RESULTS

ThedescriptionofthestudysamplebycountrytypologycanbefoundinTable1.

Severalpatternswerepresentinallcountrytypologies:womenhadpoorerhealththan

men;thepercentageofwomenwithlowereducationallevelwashigherthanamong

9

men;womeninthesampleweremoreoftenseparated,divorcedorwidowedthan

men;womenweremoreoftenemployedintheservicessectororinhouseworkthan

menwhilemenweremoreofteninmanualjobs.

Prevalenceofpoorhealthrangedfrom16.6%formeninGreeceto68.4%forwomen

intheRussianFederation(Table2).Statisticallysignificantgenderinequalitiesinhealth

werenotobservedinDual-earnerorMarket-orientedcountries,whereaswomenhad

ahigherprobabilityofhavingpoorhealththanmeninTraditional-Centralcountries

(PR=1.13,95%CI:1.07-1.21),Traditional-Southerncountries(PR=1.27,95%CI:1.19-

1.35)andContradictorycountries(PR=1.08,95%CI:1.05-1.11).Thereweresome

outlierssuchasSwedenamongtheDual-earnercountries,withaPRof1.45,the

NetherlandsamongtheTraditional-Centralcountries,withaPRof1.31,andBulgariain

thegroupofContradictorycountrieswithaPRof1.33.

Genderinequalitiesvariedslightlywhenstratifyingbydifferentindividual-levelsocial

determinantsofhealth(Table3).InTraditional-Southerncountriestheywerepresent

inallagegroupsover35yearswithPRvaluesofaround1.30,whileinContradictory

countriestheywerepresentinthe20to64agerangeandespeciallynotableinthe20

to34agegroup.InTraditional-CentralandMarket-orientedcountries,thoughmodest,

inequalitiesweresignificantonlyintheoldestgroup.Incountriesofboththe

Traditionaltypologiesgenderinequalitiesseemedmoremarkedamongthosewith

lowereducation(PR=1.19inTraditional-Centraland1.26inTraditional-Southern).In

Dual-earnercountriesinequalitieswerefoundamongstudents(PR=1.51,95%CI:1.07-

2.15),alsointhesetypologiesinequalitiesseemedmorenotableamongpeoplenot

marriedbutcohabiting(PR=1.33inTraditional-Centraland1.64inTraditional-

Southerncountries).ExceptforMarket-orientedcountries,inequalitieswerehigherfor

thoseworkinginservices,butwereonlysignificantforTraditional-Centraland

Contradictorycountries.Inequalitieswereespeciallymarkedamongthoseinmanual

occupationsinTraditional-Southerncountries(PR=1.43,95%CI:1.15-1.78)andMarket-

orientedcountrieswheretheywerealmoststatisticallysignificant(PR=1.43,95%CI:

0.98-2.10).InContradictorycountriesgenderinequalitieswerefoundforthethree

categoriesofworkers.

10

Figure1presentstheresultsofthemultilevelmodels.Beforeadjustmenttherewere

genderinequalitiesinTraditional-Central(PR=1.12),Traditional-Southern(PR=1.27)

andContradictorycountries(PR=1.21).OnlyinequalitiesinTraditional-Southern

countriesweresignificantlyhigherthanthoseinDual-earnercountries(reference

category).WhenadjustingforGEMorforGEMandGDP,estimatesdidnotchange

muchbutgenderinequalitiesinTraditional-Southerncountriesceasedtobe

statisticallydifferentfromthoseobservedinDual-earnercountries.After

additionaladjustmentforindividualvariablesinequalitiesdiminishedslightlyin

Traditional-Southerncountries(PRfrom1.26to1.20)andContradictorycountries(PR

from1.16to1.09),meaningthatindividualvariablesexplainedabout23%and44%of

theinequalitiesobservedinthesecountries,respectively.

DISCUSSION

Thisstudyhasfoundgenderinequalitiesinself-perceivedhealthincountrieswith

TraditionalfamilypoliciesandincountrieswithContradictoryfamilypolicies.However,

onlygenderinequalitiesinTraditional-Southerncountriesweresignificantlydifferent

fromthoseinDual-earnercountries.Theindividualsocialdeterminantsofhealth

consideredseemtoplayarole,thoughmodest,inexplainingthesehigherinequalities.

Genderinequalitiesinhealthbycountrytypology

Inthisstudy,genderinequalitiesinhealthwerenotfoundincountrieswithDual-

earnerorMarket-orientedpolicies.AprevioussystematicreviewhasshownthatDual-

earnercountries(Nordic)seembestatpromotingwomen’shealth(Borrell,etal.,

2014).Welfarestatepoliciesmaycontributetogenderdifferencesingeneralhealth

beingsmaller,ornon-existent.Inthesecountriesthereisastronginvolvementofthe

state(mainlythroughservices)inthecareofchildren,theelderlyandthehelpless

(Sainsbury,1999),whilefathersarestimulatedtotakeamoreactivepartincaringfor

theirminorchildren,whichcanbeassumedtorelievewomenfromcareworkand

11

strengthentheiroccupationalcommitment(Korpi,etal.,2013).ComparedtotheDual-

earnercountries,countrieswithMarket-orientedpoliciesareattheoppositeendof

thepublic-supportspectrum(Thévenon,2011).Howeverwedidnotfindgender

inequalitiesinhealthinthesecountries,coincidingwiththefindingbyBambraetal.

(Bambra,etal.,2009)ofreversedgenderinequalitiesinself-ratedhealthintheUK.

Theauthorsofthatstudyalsohighlightedhowchallengingtheseresultswerefor

welfarestateregimetheory.Wemustpointoutthatinourstudy,inMarket-oriented

countriesgenderinequalitieswerelargeandalmoststatisticallysignificantamong

manualworkers,possiblybecausetheyarenotabletoaffordtheservicesforfamilies

offeredbythemarket.InTraditional-CentralandContradictorycountrieswomentend

tohaveahigherprevalenceofadversegeneralhealth,comparedtomen.

Contradictorycountrieshaveahighfemaleparticipationinthelabourmarket,

inheritedfromthecommunistera,andstillhavemuchmorepublicservicesfor

dependentpeoplethan(some)Traditionalcountries.Itshouldbenotedhowever,that

theyareveryconservativeinthegenderbalanceofpoweratthefamilylevel,andthus

combineahighfemaleparticipationinpaidworkwithatraditionaldivisionof

housework.Traditional-Centralcountrieshavehighlevelsoftraditionalfamilysupport

wherewomenareresponsiblefordomesticandfamilyworkandenterthelabour

marketmostlyassecondaryearners.Inprinciplethiscouldreinforcethehypothesis

thatwomen’spoorerhealthcouldberelatedtotheirlackofpower,statusand

financialresources.

Finally,Traditional-Southerncountriespresentsignificantlyhigherinequalities

comparedtoDual-earnercountries.Traditional-Southerncountriesarecharacterized

byastrong‘‘familialism’’,withafamily/kinshipsolidaritymodelbasedonan

asymmetricalgenderdivisionofwork,lowfemaleparticipationinthelabourmarket,

theessentialroleofwomenbeingprovidingcarewithinkinships,limitedprovisionof

careservicesandlowfinancialfamilysupportbythestate.Womenareentitledtoa

relativelyshortpaidperiodofchild-relatedleaveandthereislessextensiveprovision

ofchildcareservicesthanothercountries,whilefathers’specificentitlementto

paternityleavehasonlyrecentlybeenincorporatedandisverylimited(Thévenon,

2011).Inadditionithasbeenarguedthat,inthecontextofthecurrenteconomic

12

crisis,womenhavebeenpushedintothelabourmarket,whichmayaddtotheir

greaterdomesticworkload,duetominimalchildcaresupportandmen’slimited

contributiontohousework(Artazcoz,etal.,2013).Someofthesecountries(Spain,

GreeceandPortugal)alsohadlongperiodsoffascistgovernmentsduringthe

twentiethcenturywithhighrepressiondirectedattheworkingclass,regressivefiscal

policies,underdevelopedwelfarestates,andasignificantroleoftheCatholicChurch

thatreliedonwomenforthecareoffamilymembersandactivelypromotedthe

traditionalfamilymodel(Navarro&Shi,2001).Theexistinggenderinequalitiesin

healthinTraditional-Southerncountriesareconsistentwiththosefoundinother

studies(Bambra,etal.,2009),whilestudieslookingatdifferenthealthindicatorssuch

asdepression,havealsofoundthatgenderdifferencesweregreaterinEasternand

SouthernEuropeanCountriesandsmallestinNordiccountries(VandeVelde,etal.,

2010).

Wehavefoundcertainoutlier-countries,inwhichinequalitieswerehigherthaninthe

restoftheirgroup.ThishappenedforexamplefortheNetherlands.TheDutchwelfare

statehassometimesbeenclassifiedasasocial-democraticone(Bambra,2007).

However,ontheotherhand,Dutchwomenhavehighsharesofrelativelyprecarious

part-timework.AnothercountrywithhighgenderinequalitieswasSweden,mainly

duetotheverygoodhealthreportedbySwedishmen.Itseemsthatthiscountry,

althoughoneofthemostegalitarianintheworld,hasoneofthemoststronglygender

segregatedlabourmarkets(Stenmark,2010),withwomenmorelikelytoworkinthe

publicsector,inpart-timeemploymentandwithlowerwages.Moreover,ithasbeen

unabletosignificantlyaltertheunevendistributionofpowerintheeconomicsectoras

opposedtothepoliticalsectorwhereahighdegreeofgenderequityhasbeen

reached,andunabletofulfillthepoliticalgoalofsharedparentalresponsibilities

(Svensson&Gunnarsson,2012).Nevertheless,asotherNordiccountriesmayalso

sharesomeofthesefeatures,thisfindingdeservesconfirmationandfurther

explorationinmoredetailedstudies.

Individualsocialdeterminantsasmediatorsandeffectmodifiers

13

Inequalities inTraditional-SouthernandContradictorycountries fell slightlywhenwe

controlled for individual-level mediators. In Traditional-Southern countries, in fact,

inequalitieswereespeciallyhighinolderpeople, inthosenotmarriedbutcohabiting

andinmanualworkers.Apreviousstudyfoundthatinmanualclasses,unmarriedbut

cohabitingwomenhadworsehealththanmarriedandcohabitingwomen(Artazcoz,et

al., 2011). It couldbe that cohabitantsmore frequentlyhave relationshipsofpoorer

quality andwith greater instability compared tomarried couples and thatmarriage

qualityaffectswomenmore thanmen. InTraditional-SoutherncountriesCatholicism

historically had a very important role (Ferrera, 1996), this could be a reason why

marriageseemstobemoreimportantherethaninothertypologies.

Regardinggenderinequalitiesbyemploymentstatusgenderinequalitiestendedtobe

lowerinprofessionalworkersthaninotheroccupationalcategories;afactthatdiffers

fromtheresultsofthestudybyCampos-Sernaetal.(2013)whichfoundthatgender

inequalitiesintheexposuretowork-relatedpsychosocialhazardswerepresentinthe

majorityofwelfarestateregimesbutweremoreimportant inmangers/professionals

thaninclerk/service/shopandmanualworkers.

Genderhealthinequalitiesinmanualclassesexistedinallcountrytypologiesexceptin

Dual-EarnerandTraditional-Central.KorpiarguedthatDual-earnerpoliciesappearto

be more efficient in terms of getting women without tertiary education into

employment(Korpi,etal.,2013).PerhapsinTraditionalcountriesthereisaselection

processwhereby onlywomen in financial strain enter the labourmarket asmanual

workers. Another possibility could be that in Traditional-Southern countries a

disproportionate number of femalemanualworkers are employed in poorer quality

jobs. InContradictory countries it seems that the sourcesof gender inequality could

differ from those in Traditional countries as inequalities were mostly observed in

youngwomenandinthethreegroupsofworkers.Thiscouldreflectthedoubleburden

of family and paid work for women since in these countries although women’s

engagementinthelabourmarketishighthereisalowemphasisonpoliciesenabling

womentocombinemotherhoodwithpaidwork(Thévenon,2011).

14

Thereweresurprisinglylargegenderinequalitiesingeneralhealthamongstudentsin

Dual-earnercountries.Someauthorshavepointedoutthatthelonghistoryoffocusing

ongenderequalityinthosecountriesmeansthatyoungergenerationsaretakingitfor

granted(Sümer,2009).Futurestudieswillhavetoconfirmthisresult.Itisalso

remarkablethatinthesecountriesgenderinequalitiesarehigheramongservice

workers.Thelatterdifferencecouldwellbeexplainedbythedifferenttypesofservice

jobsthatmenandwomenperform,especiallyregardingpay,butalsocareerprospects

andworkingenvironment–withwomenbeinginpublicsectorhealthandcaringjobs

andmeninprivatesectorjobs,primarilyinsales.

Theroleofcountrylevelgenderequality

Inthisstudytheindicatorofgenderequalitydidnotmediatetheeffectofthecountry

typologyoninequalities.Somestudieshavefoundthatdifferentmeasuresofgender

equalitywereassociatedwithgenderinequalitiesincertainhealthoutcomes(Van

Tuyckom,etal.,2013;Varkey,etal.,2010;Wells,etal.,2012),thoughothershavenot

(Dahlin&Härkönen,2013;Grittner,etal.,2012)andsomehavefoundthattheyhave

aneffectonlyincertainsocialsubgroups(Schaap,etal.,2009;VandeVelde,etal.,

2013).Asshownintheabove-mentionedreview,instudiesperformedintheUnited

States,genderequalityatthestatelevelhasalsobeenassociatedwithbetterhealth

outcomesinwomenandlowergenderinequalitiesinhealth(Borrell,etal.,2014).In

ourmodels,thoughnotsignificant,thedirectionoftherelationshipindicatedthat

higherGEM-levelswererelatedtolowerhealthinequalityatthecountrylevel(results

notshown).However,theGEMdidnotmediatetheeffectofpolicytypology.One

possibilityisthat,astheindicatorwassignificantlycorrelatedwiththecountry

typology(resultsnotshown),thetypologysomehowcapturedtheinequalitiesbetter

thantheindexdid.Anotherpossibilitycouldbethatourindicator,theGEM,ismainlya

measureofpoweroragency,whilethepathwaythroughwhichthetypologyactsisa

differentone.

Limitations

15

Thisstudyhascertainlimitations.Inthefirstplace,toourknowledge,noneofthe

existinggenderregimetypologiesincludedallthecountriesthatwereavailableinour

data.Forthatreasonweoptedforusingafamilypolicytypology.However,asstated

previously,thefamilypolicymodelcanbeseenasanindicatorofthedegreetowhich

country-levelpoliciessupportwomen’slabourforceparticipationwhichaffects

women’sself-perception,identityandbargainingpositionwithinthefamily(Backhans,

etal.,2011)andpromotesgenderequality.Inaddition,itseemsthereisacertain

heterogeneityamongtheavailabletypologiesastowherecountriesareclassified.For

example,withintheContradictorytype,someauthorshaveassertedthatcountries

suchasSloveniaorEstoniaareevolvingtowardsaDual-earnertype(Ferrarini&

Sjoberg,2010).Inaddition,Hungaryseemstobeanoutlierinitsgroupsinceit

providesmuchmorecomprehensivesupporttoparentswithyoungchildrenand

SlovakiaappearstobecomparabletomostSouthernEuropeancountries(Thévenon,

2011).Weperformedasensitivityanalysiswithoutthesecountriesandresultshardly

changed(resultsnotshown).

Also,itisworthmentioningthatwefoundlargebetween-countryinequalitiesin

people’sself-perceivedhealth.Infactpoorhealthwashighlyprevalentinsome

SoutherncountriesandinmostEasterncountries.Thisresulthasbeenreportedby

earliercomparativestudies(Carlson,1998;Eikemo,etal.,2008).Apossible

explanationforthisfindingcouldbedifferencesinwealthbutalsocountrydifferences

inpeople'sperceptionofpoorhealth(Jurges,2007).However,althoughitmayhavean

effectontheactuallevelsofself-perceivedhealth,wedonotexpectittohaveabig

effectongenderinequalities.

Finally,itisnecessarytocommentthattheeconomicrecessionthatstartedattheend

of2008hashaddifferentialeffects(anddifferentialtiming)inmanyofthesecountries.

Probably,theimpactofbudgetcutsonpublicgenderequalitypolicieshasbeen

greaterinSouthernEuropeancountries,butthesehavemainlybeenappliedsince

2010.

CONCLUSIONS

16

Genderinequalitiesinself-perceivedhealthwerehigherincountrieswithfamily

policiesthatwerelessorientedtogenderequality,especiallythoseinSouthern

Europe.Thiswaspartiallyexplainedbygenderinequalitiesintheindividualsocial

determinantsofhealthincludedinthisstudybutnotbythecountry-levelgender

equalitymeasureused(GEM).

17

TABLESANDFIGURES

Box1.TypologiesofcountriesaccordingtoKorpi’sfamilypoliciesmodel(Korpietal.2013;

FerrariniandSjöberg2013).

Typology Countries CharacteristicsDual-earner Denmark Publicpoliciesenableatransferofchildcarefromthe

familytothepublicsectorandstimulatefathersto

takemoreactivepartincaringfortheirminor

children.

Finland

Norway

Sweden

Traditional-Central Belgium Thesecountrieshavetraditionalfamilypolicieswith

highsupporttoallfamilies,asforexample:child

allowancesforminorchildren,part-timeday-care

services,homecareallowancesormarriagesubsidies.

Germany

France

Netherlands

Traditional-Southern

Cyprus Thesecountrieshaveresidualfamilypolicieswithlack

ofsupporttofamiliesandrelyonunpaidhelp.Spain,

GreeceandPortugalhavehadalongperiodorright-

wingdictatorship.

Spain

Greece

Portugal

Market-oriented Switzerland Absenceofstrongactiontosupporthouseholds,the

marketistheprincipalinstitutiongoverning

individuals’andfamilies’accesstoresources

UnitedKingdom

Ireland

Contradictory Bulgaria Simultaneouslyattemptstobothpreserveahighly

gendereddivisionofdomesticlabourandsupportthe

dual-earnerfamily.Consistofformersocialist

countrieswherefamilypolicieshavechangedafterthe

transition(beforetheyweremoresupportingto

women’slabourforceparticipation).

CzechRepublic

Estonia

Croatia

Hungary

Lithuania

Poland

RussianFederation

Slovenia

Slovakia

Ukraine

18

Table1.Distributionofthestudysampleinrelationtotheotherindividualvariablesunderstudyformenandwomen,ineachcountrytypology(%). Dual-earner Traditional-Central Traditional-South Market-oriented Contradictory Men Women Men Women Men Women Men Women Men WomenN 3,243 3,256 4,014 4,278 3,456 4,369 3,018 3,486 9,006 12,017Self-perceivedhealth Good 73.6 71.3 68.5 65.4 72.4 64.2 79.4 77.8 57.4 48.8Poor 26.4 28.7 31.4 34.5 27.6 35.8 20.5 22.2 42.3 51.0missing 0.0 0.0 0.1 0.1 0.0 0.0 0.1 0.0 0.2 0.2Age 15-19 7.2 8.5 8.2 6.5 6.6 4.6 7.5 7.9 6.8 7.920-34 20.2 19.5 18.7 20.8 22.9 22.0 26.0 21.8 25.9 21.835-49 25.1 23.8 25.3 28.6 25.5 26.5 25.4 27.9 24.2 27.950-64 26.0 24.7 27.2 25.8 22.1 24.8 22.5 24.4 26.4 24.465+ 21.5 23.5 20.4 18.3 22.8 21.9 18.4 17.9 16.2 17.9missing 0.0 0.0 0.2 0.0 0.1 0.2 0.2 0.1 0.5 0.1Borninalow-incomecountry No 95.3 94.8 92.8 92.7 93.5 92.9 89.0 91.9 94.9 94.3Yes 4.2 4.8 6.9 6.9 6.4 7.1 10.0 7.7 4.6 5.3missing 0.5 0.4 0.3 0.4 0.1 0.0 1.0 0.4 0.5 0.4Educationallevel Uptolowersecondary 25.4 28.8 27.0 31.1 51.4 54.3 33.1 35.2 21.0 21.9Uppersecondary 50.1 42.9 51.2 48.8 32.8 31.1 48.3 45.6 60.1 54.9Tertiary 24.3 27.8 21.4 19.8 15.7 14.6 16.6 17.3 18.6 23.0missing 0.2 0.5 0.4 0.3 0.1 0.0 2.0 1.9 0.3 0.2Partnerstatus Nevermarried 28.2 28.6 26.5 21.1 29.8 21.0 33.4 26.5 28.2 19.3Separated/divorced/widowed 5.5 12.4 8.0 16.2 6.0 16.9 7.9 15.7 8.7 23.7Notmarriedcohabiting 17.0 15.6 11.3 12.1 5.4 4.9 9.0 9.6 8.1 8.0Married 49.1 43.3 54.2 50.5 58.7 57.2 49.6 48.1 54.7 48.6

19

Dual-earner Traditional-Central Traditional-South Market-oriented Contradictory Men Women Men Women Men Women Men Women Men Womenmissing 0.1 0.1 0.0 0.0 0.1 0.0 0.1 0.1 0.3 0.4Employmentstatus Professionalpaidwork 29.5 27.4 27.6 25.8 15.6 11.2 22.1 20.1 17.7 19.2Servicespaidwork 6.6 16.4 7.5 14.6 10.3 15.6 7.7 16.9 7.0 13.9Manualpaidwork 20.1 5.1 19.0 5.8 23.2 9.6 22.1 5.1 26.3 8.1Student 11.0 13.9 9.9 9.0 8.4 7.6 11.2 10.0 10.6 9.0Unemployed 5.0 3.6 4.4 4.5 11.2 10.2 10.9 5.6 9.7 6.9Disabled/retired 25.7 27.9 27.2 21.9 28.7 21.1 22.3 20.4 25.2 31.0Housework 0.7 4.4 1.7 16.1 0.6 23.4 1.6 20.3 0.9 10.2Others 0.9 1.1 2.0 1.7 1.3 1.1 1.1 1.2 0.9 0.6missing 0.5 0.2 0.7 0.6 0.7 0.2 1.0 0.4 1.7 1.1

20

Table2.Numberofcases,age-standardisedprevalenceofpoorhealthandprevalenceratioofpoorhealthcomparingwomenwithmen,ineachcountryandcountrytypology.GenderEmpowermentMeasure(GEM)bycountry.

Countrytypologyandcountry Men Women PR 95%CI GEM N % N % Dual-earner Denmark 809 24.7 767 22.2 0.89 (0.75-1.05) 0.896Finland 911 33.1 967 32.3 0.98 (0.87-1.09) 0.902Norway 805 24.0 743 25.0 1.05 (0.88-1.24) 0.906Sweden 718 17.9 779 26.3 1.45 (1.20-1.75) 0.909Total* 3.243 23.8 3.256 26.5 1.05 (0.98-1.14) -Traditional-Central Belgium 820 21.8 884 25.3 1.15 (0.98-1.35) 0.874Germany 1.556 39.2 1.475 42.4 1.08 (0.99-1.18) 0.852France 802 31.2 926 34.3 1.11 (0.96-1.28) 0.779Netherlands 836 22.8 993 29.8 1.31 (1.12-1.53) 0.882Total* 4.014 33.8 4.278 37.0 1.13 (1.07-1.21) -Traditional-Southern Cyprus 482 21.4 593 28.6 1.33 (1.11-1.60) 0.603Spain 927 32.5 958 42.6 1.28 (1.14-1.44) 0.835Greece 1.189 16.6 1.526 22.7 1.39 (1.19-1.63) 0.677Portugal 858 33.9 1.292 40.7 1.21 (1.09-1.34) 0.753Total* 3.456 30.2 4.369 38.6 1.27 (1.19-1.35) -Market-oriented Switzerland 772 17.2 734 18.8 1.12 (0.91-1.38) 0.822UnitedKingdom 1.057 28.3 1.365 27.9 0.98 (0.86-1.12) 0.790Ireland 1.189 16.9 1.387 18.5 1.11 (0.92-1.32) 0.722Total* 3.018 26.3 3.486 26.5 1.04 (0.95-1.15) -Contradictory Bulgaria 1.064 26.0 1.370 34.8 1.33 (1.20-1.48) 0.613CzechRepublic 1.190 39.7 1.196 39.3 0.97 (0.88-1.07) 0.664Estonia 722 52.1 1.071 50.3 0.96 (0.88-1.04) 0.665Croatia 720 37.9 921 38.0 0.98 (0.87-1.11) 0.618Hungary 715 45.1 846 50.2 1.09 (1.00-1.20) 0.590Lithuania 603 48.1 1.074 53.8 1.10 (0.96-1.25) 0.628Poland 841 37.8 910 41.2 1.08 (0.97-1.21) 0.631RussianFederation 1.064 58.3 1.531 68.4 1.18 (1.10-1.27) 0.556Slovenia 651 39.6 750 42.8 1.08 (0.96-1.21) 0.641Slovakia 717 39.6 1.136 41.1 0.99 (0.86-1.14) 0.663Ukraine 719 61.6 1.212 67.7 1.12 (1.02-1.22) 0.461Total* 9.006 52.0 12017.0 61.0 1.08 (1.05-1.11) -

*ageandcountrystandardised

21

Table3.Prevalenceratio(PR)and95%confidenceinterval(95%CI)ofpoorhealthaccordingtogender(womencomparedtomen)globallyand

stratifyingbyotherindividualsocialdeterminantsofhealth,adjustingbyageandcountryineachcountrytypology.

Dual-earner Traditional-Central Traditional-Southern Market-oriented Contradictory PR 95%CI PR 95%CI PR 95%CI PR 95%CI PR 95%CI 1.05 (0.98-1.14) 1.13 (1.07-1.21) 1.27 (1.19-1.35) 1.04 (0.95-1.15) 1.08 (1.05-1.11)

Age 15-19 1.45 (0.93-2.26) 1.37 (0.88-2.13) 0.59 (0.22-1.60) 1.09 (0.55-2.16) 1.2 (0.84-1.71)

20-34 1.13 (0.86-1.48) 1.21 (0.99-1.48) 1.04 (0.76-1.43) 1.29 (0.95-1.74) 1.23 (1.08-1.39)

35-49 1.00 (0.83-1.22) 1.09 (0.94-1.26) 1.36 (1.12-1.66) 0.96 (0.78-1.19) 1.11 (1.03-1.20)

50-64 1.07 (0.93-1.22) 1.09 (0.98-1.21) 1.32 (1.16-1.52) 0.9 (0.75-1.07) 1.08 (1.03-1.13)

65+ 1.02 (0.92-1.14) 1.18 (1.07-1.29) 1.24 (1.16-1.33) 1.16 (1.00-1.34) 1.02 (0.99-1.06)

Borninlow-incomecountry

No 1.04 (0.96-1.12) 1.14 (1.07-1.22) 1.26 (1.18-1.35) 1.08 (0.97-1.19) 1.09 (1.05-1.12)

Yes 1.44 (0.98-2.12) 1.03 (0.82-1.29) 1.29 (0.91-1.82) 0.7 (0.47-1.05) 1 (0.90-1.11)

Education

Uptolowersecondary 1.09 (0.97-1.22) 1.19 (1.07-1.33) 1.26 (1.18-1.35) 0.99 (0.87-1.13) 1.05 (1.00-1.11)

Uppersecondary 1.05 (0.94-1.18) 1.07 (0.99-1.17) 1.14 (0.94-1.39) 1.11 (0.94-1.30) 1.09 (1.04-1.13)

Tertiary 1.01 (0.82-1.24) 1.01 (0.84-1.22) 1.24 (0.95-1.63) 1.07 (0.78-1.46) 1.1 (1.01-1.20)

Cohabiting

Nevermarried 0.95 (0.82-1.09) 1.07 (0.91-1.25) 1.08 (0.85-1.37) 1.13 (0.93-1.38) 1.04 (0.93-1.15)

Separated/divorced/widowed 0.92 (0.74-1.15) 1.01 (0.89-1.14) 1.10 (0.97-1.24) 1.02 (0.85-1.23) 1.02 (0.96-1.08)

Notmarriedcohabiting 1.20 (0.95-1.51) 1.33 (1.07-1.65) 1.64 (1.18-2.28) 1.09 (0.77-1.54) 1.15 (1.01-1.31)

Married 1.05 (0.94-1.17) 1.12 (1.03-1.22) 1.29 (1.19-1.40) 0.98 (0.85-1.13) 1.1 (1.06-1.15)

Employmentstatus

Professionalpaidwork 1.02 (0.82-1.28) 1.02 (0.86-1.21) 1.18 (0.86-1.62) 0.80 (0.59-1.10) 1.26 (1.12-1.41)

Servicepaidwork 1.33 (0.94-1.89) 1.29 (1.00-1.65) 1.32 (0.95-1.84) 0.90 (0.62-1.29) 1.24 (1.07-1.43)

Manualpaidwork 1.08 (0.81-1.43) 1.13 (0.92-1.39) 1.43 (1.15-1.78) 1.43 (0.98-2.10) 1.33 (1.21-1.45)

Student 1.51 (1.07-2.15) 1.15 (0.78-1.68) 1.01 (0.49-2.10) 1.20 (0.68-2.10) 1.13 (0.86-1.49)

Unemployed 1.29 (0.92-1.82) 1.18 (0.91-1.54) 1.22 (0.95-1.56) 0.97 (0.67-1.41) 1.1 (0.97-1.26)

Disabledorretired 1.00 (0.92-1.10) 1.17 (1.09-1.27) 1.29 (1.20-1.39) 1.03 (0.92-1.16) 0.98 (0.95-1.01)

Housework 1.06 (0.41-2.78) 0.96 (0.66-1.39) 1.11 (0.69-1.78) 0.81 (0.48-1.37) 1.28 (0.98-1.68)

Others 0.99 (0.48-2.03) 2.01 (1.11-3.64) 1.15 (0.65-2.04) 1.37 (0.48-3.88) 1.02 (0.64-1.64)

22

Figure1.Multilevelassociationsbetweengenderandself-perceivedhealthineachcountrytypology(PR:prevalenceratiosand95%CI:95%confidenceintervals).Note:*=significantlydifferentfromdual-earner(p<0.05).

Figure1a.Emptymodel

Figure1c.Individualvariables+GEM

Figure1b.Individualvariables

Figure1d.Individualvariables+GEM+GDP

23

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