The WHO report on social determinants of health concludes that reducing the health gap is only possible through addressing gender inequities [1]. Empowerment of women is considered as a key to achieving fair distribution of health. In this cross-sectional study, the difference in poor self-rated health between men and women could be explained by a higher prevalence of financial insecurity and experiences of condescending treatment among women.
In previous studies, social relations in the form of social capital, support, and networks have been found to be important determinants of self-rated health [6, 10, 13]. It is assumed that the quality of social interaction results in psychological reactions, which in turn affect health. In previous studies perceived discrimination has been found to be a strong determinant of both physical and mental health [16]. We did not measure perceived discrimination directly, but it can be assumed that if a person has been treated several times in a condescending manner this can be experienced as discrimination. In the literature, this type of discrimination is often referred to as everyday interpersonal discrimination i.e. being treated badly in everyday situations [23]. Therefore there is probably a high correlation between perceived discrimination and condescending treatment, but this, of course, has to be confirmed in subsequent studies.
Psychosocial pathways are, however, likely to only partly explain social differences in self-rated health. Pathways based on material indicators, such as economic hardship and financial insecurity, are also important [7–9, 14]. In our study, adjusting only for condescending treatment or for financial insecurity was not enough to explain the higher prevalence of poor self-rated health among women. But when the two factors were adjusted for simultaneously, the difference in poor self-rated health became statistically non-significant. Both factors were also strongly associated with poor self-rated health. It should be noted, however, that the original difference in self-rated health between women and men was not that large.
Women had higher educational level than men which is in line with the official statistics [21]. In spite of this they had a higher level of financial insecurity than men. This suggests that education does not “pay-off” as much among women as it does among men. In Sweden, women’s incomes are in general 75% of men’s incomes. Even though women participate in the working force almost to the same extent as men do, the labor market is strongly segregated with women working more often in occupations with lower salaries [21]. In addition, women with small children often work part-time and women spend, in general, more time in domestic work than men do whereas having children does not affect the working time of men [21]. The fact that women have higher educational level than men but have worse economic situation can be interpreted as a structural level, unobserved discrimination [18]. It is against the WHO report’s intention of equality in terms of equitable distribution of power, money and resources and the structural drivers of those conditions of daily life [1]. It also suggests that promoting high education may not be sufficient to improve the health of women if there are other structural mechanisms that counteract its effect.
The response rate in our study was not very high (59%) but similar to other population based studies in Sweden [20, 22]. The response rate was lower among younger than among older subjects and in men compared with women. The respondents had also somewhat higher educational level than the general population of the same age. It is possible that men with poor health are underrepresented among the respondents and therefore the true difference in self-rated health between men and women may be smaller. Also the financial situation of men can be overestimated. On the other hand, the poorer health and economic situation of women in Sweden is well documented [21]. The level of condescending treatment among women can be overestimated in the case of response bias. But current evidence shows, on the contrary, that women tend rather to underreport than to over report discriminatory experiences [24]. This can be explained by the notion that subordinate groups are more likely to deny or underreport discriminatory experiences because they may internalize negative attitudes by accepting the dominant culture’s values and role in society [18]. Based on these arguments it is unlikely that response bias would entirely explain the results obtained.
A major limitation of the present study is that it based on cross-sectional data. It is therefore not possible to draw conclusions about which factors are causes and which are effects of poor self-rated health. Persons who have experiences of condescending treatment may have higher risk of poor health, but persons with poor health may be treated condescendingly due to their health status. Also, the relationship between financial insecurity and health can be reverse, if persons with poor health run into financial difficulties, for example due to receiving sickness compensation instead of salary. We took into account the possible reverse effect by adjusting for longstanding illness. Adjusting for longstanding illness did not, however, affect remarkably the estimated odds ratios suggesting that either this reverse effect was not substantial or that we did not capture it very well by adjusting for longstanding illness. In any case, prospective studies have shown that both financial insecurity [14, 15] and poor social relations [13, 14] as well as perceived discrimination [16] have independent causal effects on self-rated health.
A limitation of the study is also that both the risk factors and the outcome were self-reported. For self-rated health this is the only option and it has been shown to be a good measure of health [2–5]. What comes to financial insecurity, there is some evidence that self-reported measures of economic difficulties are more strongly related to health than measures based on objective economic situation such as low income [20]. Previous studies have used different measures of financial insecurity [14, 15]. Our measure was similar to one of two questions used to measure self-reported economic difficulties in the Swedish study [20]. Self-reported condescending treatment has previously been shown to be strongly associated with poor self-rated health [12] and mental health symptoms [25]. Similar results have been reported for the association between self-reported experiences of discrimination and psychological distress [22]. There was also a dose–response relationship between condescending treatment and self-rated health, which has also been reported for perceived discrimination [26]. Experiences of discrimination are usually measured through self-reports and different studies have often used different measures of perceived discrimination since there has been a lack of validated instruments that could have been used in large scale epidemiologic studies [16, 18].
We adjusted for educational level and longstanding illness in the analyses, because these factors are associated with self-rated health and differ between women and men. There was, however, a statistically significant difference between women and men in self-rated health even when educational level and longstanding illness were taken into account. This difference was also similar among younger and older subjects. In addition, the questions on financial insecurity and condescending treatment can have different meaning for persons with different educational levels. Persons with a longstanding illness such as depression, on the other hand, can be more likely to interpret social situations as negative. Since these factors were accounted for, our results cannot be explained to any larger extent by differences in educational level or longstanding illness between women and men. We also investigated the difference in self-rated health between women and men and the effect of financial insecurity and condescending treatment within different educational levels but the results were fairly similar indicating that the results do not differ by educational level.
In our study, it was the higher prevalence of financial insecurity and experiences of condescending treatment among women that explained the difference in poor self-rated health between women and men. It is, however, possible that similar results would have been obtained using some other measures of material conditions and psychosocial factors closely related to these two indicators. The strength of our study is that it is based on a very large general population and includes a wide age range. The robustness of the results irrespective of age group and educational level further strengthens the implications of the results.
The difference in self-rated health between women and men was not very large, but similar to several other West-European countries [11]. Even in Sweden where the opportunities for men and women in society are relatively equal, this difference exists and is relatively consistent between age groups and educational levels. The findings of present study imply that gender differences in health can be explained by material conditions and psychosocial factors that can be measured at individual level but are produced at structural and interpersonal level through mechanisms of different types of discrimination [18]. This is important since women comprise half of the population and addressing these differences has therefore a large effect on health and on health inequities in the general population [1, 27].
