Abstract

In recent years, a great deal of attention has been paid to gender inequities in health. However, while we have a good body of evidence on the impact of gender on the health and vulnerability of women and men, we have not yet been able to generate sufficient evidence on effective interventions that can transform this situation or can influence public health policy making. Only a limited number of educational interventions on gender-sensitivity, gender bias in clinical practice and policies to tackle gender inequalities in health have been formulated, implemented and evaluated. Even in the current pandemic situation caused by SARS-CoV2, we have seen the lack of gender mainstreaming reflected in the global response. This happens even when we have tools that facilitate the formulation and implementation of actions to reduce gender inequities in health. We consider that the current initiatives organized to carry out advocacy activities on gender inequity in health to be very positive. In the same line of these initiatives, we propose that while academic and institutional research on gender and health remains essential, we need to shift the focus towards action. In order to move forward, we need public health researchers questioning what public health practice need to do to address gender inequities and shake structural and social power inequities in order to increase the gender equity in health.

Keywords:
Gender bias; Sexism; Public health practice; Healthcare disparities; Gender equity

Resumen

En los últimos años se ha prestado mucha atención a las desigualdades de género en salud. Si bien hay abundante evidencia sobre el impacto del género en la salud y la vulnerabilidad de mujeres y hombres, aún no se ha podido generar evidencia suficiente sobre intervenciones efectivas que puedan transformar esta situación o que puedan influir en la formulación de políticas de salud pública. Solo se han formulado, implementado y evaluado un número limitado de intervenciones educativas sobre la sensibilidad de género, de intervenciones para reducir el sesgo de género en la práctica clínica y de políticas para abordar las desigualdades de género en la salud. Incluso en la actual situación de pandemia causada por el SARS-CoV2 se ha visto la falta de transversalización de género reflejada en la respuesta global. Esto sucede incluso cuando se cuenta con herramientas que facilitan la formulación y la implementación de acciones para reducir las inequidades de género en salud. Consideramos que las iniciativas actuales para realizar acciones con incidencia sobre la inequidad de género en salud son muy positivas. En esta línea, proponemos que, si bien la investigación académica e institucional sobre género y salud sigue siendo fundamental, hay que cambiar el enfoque hacia la acción. Para avanzar, es necesario que las personas que investigan en salud pública se cuestionen qué deben hacer las prácticas de salud pública para abordar las inequidades de género y hacer tambalear las inequidades estructurales y de poder social con el fin de aumentar la equidad de género en la salud.

Palabras clave:
Sesgo de género; Sexismo; Práctica de salud pública; Desigualdad en la atención sanitaria; Equidad de género

Gender is a social construct rooted in norms, roles and values considered appropriate for men and women at a given time and in a given context. Gender also refers to the relationships between men and women, and the distribution of power within those relationships.¹1. Connell R. Gender, health and theory: conceptualizing the issue, in local and world perspective. Soc Sci Med. 2012;74:1675-83. Gender is hierarchical and produces inequities that interact with other social and economic inequities. Evidence shows that gender has a significant effect on health behaviours, access to health care, and health system responses.²2. Hawkes S, Buse K. Gender and global health: evidence, policy, and inconvenient truths. Lancet. 2013;381:1783-7. In recent years, a great deal of attention has been paid to gender inequities in health, particularly those related to gender biases in epidemiological research and health care. Nature Communications published a study last year which showed that this gender bias took place in more than 700 health problems.³3. Westergaard D, Moseley P, Sørup FKH, et al. Population-wide analysis of differences in disease progression patterns in men and women. Nat Commun. 2019;10:666. A quick search in Gaceta Sanitaria of publications with gender in the title returns a result of 115 articles. In 2007 several authors who belong to The Spanish Research Network for Health and Gender (Red de Investigación en Salud y Género, RISG) acknowledged the importance of adopting a gender approach when planning and assessing policies, programmes and health services. At that time, the authors stated that the development of research on gender and health which allowed evidence-based action was scarce.⁴4. Colomer-Revuelta C, Peiró-Pérez R, López-Rodríguez RM, et al. Policies, politics and gender research. J Epidemiol Community Health. 2007;61 (Suppl 2):ii2-3.

In the same year, the Final Report of the Women and Gender Equity Knowledge Network by the World Health Organization's Commission on Social Determinants of Health was published. In this report, it was recognized that gender inequality damages the physical and mental health of girls and women across the globe, as well as that of boys and men. In addition, it was stated that acting to improve gender equity in health is one of the most direct ways to reduce health inequities, and even approaches were proposed to achieve this.⁵5. Sen G, Östlin P, editors. Unequal, unfair, ineffective and inefficient gender inequity in health: why it exists and how we can change it. Final Report to the WHO Commission on Social Determinants of Health. Geneve: Women and Gender Equity Knowledge Network; 2007. Available at: https://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf
https://www.who.int/social_determinants... However, while we have a good body of evidence on the impact of gender relations on the health and vulnerability of girls and women, we have not yet been able to generate sufficient evidence on effective interventions that can transform this situation. Moreover, we have made even less progress developing research-based ideas about gender and health to effectively influence public health policy making.

Health services should be provided with both quality and equity. The organization and provision of health services can affect accessibility and quality of encounters between patients and health professionals. However, a critical review of the evidence reveals the gap between “intention and practice” in the process of gender mainstreaming within the health sector. Healthcare providers play a key role in the move towards gender oriented clinical interventions in the healthcare system.⁶6. Celik H, Lagro-Janssen TA, Widdershoven GG, et al. Bringing gender sensitivity into healthcare practice: a systematic review. Patient Educ Couns. 2011;84:143-9. Their attitudes towards sex and gender can shape their behaviours and may bias the care they provide. Nonetheless, only a limited number of educational interventions on gender-sensitivity have been implemented and evaluated.⁷7. Lindsay S, Rezai M, Kolne K, et al. Outcomes of gender-sensitivity educational interventions for healthcare providers: a systematic review. Health Educ J. 2019;78:958-76. In addition, thirteen years after Yentl Syndrome was first defined, few studies have described and evaluated interventions aimed at tackling gender bias in clinical practice.⁸8. Alcalde-Rubio L, Hernández-Aguado I, Parker LA, et al. Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice. Int J Equity Health. 2020;19:166. In the same line, after the Beijing Declaration and Platform for Action's demand for greater attention to the social determinants of health -including gender and multisector programming- and more recently, the 2030 Agenda for Sustainable Development, few policies have been formulated, implemented, or evaluated to tackle gender inequities in health.⁹9. Crespí-Lloréns N, Hernández-Aguado I, Chilet-Rosell E. Have policies tackled gender inequalities in health? A scoping review. Int J Environ Res Public Health. 2021;18:327.

In the last year we have seen the lack of gender mainstreaming reflected in the response to the pandemic caused by SARS-CoV-2, despite the demands and work carried out by initiatives such as Global 50/50 or Lancet Gender and COVID-19 Working Group, among others. Governments worldwide responded to the pandemic with lockdowns and mobility restrictions adding the socioeconomic crisis to the health crisis, and with very different impact in men and women.¹⁰10. Kabeer N, Razavi S, van der Meulen Rodgers Y. Feminist economic perspectives on the COVID-19 pandemic. Fem Econ. 2021;27:1-29. Women are the majority in the professions that have been at the forefront of the COVID-19 pandemic. Moreover, evidence indicates that women have lost their jobs more frequently than men in numerous countries,¹¹11. Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;395:846-8. and greater increase in care work.¹²12. Bahn K, Cohen J, van der Meulen Rodgers Y. A feminist perspective on COVID-19 and the value of care work globally. Gender Work Org. 2020;27:695-9. Previous experiences, such as those related to the epidemiological outbreaks caused by the Ebola and Zika viruses, led to the coining of the term the “tyranny of the urgent” to refer to the prioritization, in global emergency situations, of biomedical (and gender blind) responses, together with the neglect of structural inequities, such as gender inequities.¹¹11. Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;395:846-8. This tyranny of the urgent exists also in the current pandemic situation.¹¹11. Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;395:846-8.

Marcos-Marcos et al.¹³13. Marcos-Marcos J, Gasch-Gallén A, Mateos JT, et al. Advancing gender equ(al)ity, lifting men's health: dealing with the spirit of our time. J Epidemiol Community Health. 2021;75:100-4. published an essay focused on the health and wellbeing of men and boys and equity versus gender equality, highlighting that the privileged social and political position of men often results in under-use of health services and higher risk-taking behaviours than women (e.g., smoking, unhealthier diet, higher alcohol and drugs abuse and higher rates of injuries and interpersonal violence). This issue is gaining interest in the study of gender inequities and there are already some initiatives to improve men's health and gender equality.

Although the overall picture is of slow and unequal progress and the number of studies showing significant improvements seems modest, studies included in different reviews reported progress⁷7. Lindsay S, Rezai M, Kolne K, et al. Outcomes of gender-sensitivity educational interventions for healthcare providers: a systematic review. Health Educ J. 2019;78:958-76.

8. Alcalde-Rubio L, Hernández-Aguado I, Parker LA, et al. Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice. Int J Equity Health. 2020;19:166.^-99. Crespí-Lloréns N, Hernández-Aguado I, Chilet-Rosell E. Have policies tackled gender inequalities in health? A scoping review. Int J Environ Res Public Health. 2021;18:327.^,1313. Marcos-Marcos J, Gasch-Gallén A, Mateos JT, et al. Advancing gender equ(al)ity, lifting men's health: dealing with the spirit of our time. J Epidemiol Community Health. 2021;75:100-4.. It is worth noting that the actions regarding gender bias in healthcare, gender-sensitivity educational interventions, and health and non-health policies aimed at the reduction of gender inequities in health, were successful. In health science education, some progress is being made -e.g., Sex and Gender Health Education Summit since 2015 have helped advance this gender agenda in health sciences¹⁴14. Rojek MK, Jenkins MR. Improving medical education using a sex- and gender based medicine lens. J Womens Health (Larchmt). 2016;25:985-9.- and also in research -e.g., the Gendered Innovations project is showing the potential for sex and gender analysis to foster scientific discovery, improve experimental efficiency and enable social equality.¹⁵15. Tannenbaum C, Ellis RP, Eyssel F, et al. Sex and gender analysis improves science and engineering. Nature. 2019;575:137-46. That is to say, some practical tools that facilitate the formulation and implementation of actions to reduce gender inequities in health are available. Along with the reported experiences, there are publications that make evidence-based recommendations or analyse facilitators and barriers which serve as a guide for the design and implementation of new actions, programs and policies aimed at reducing gender inequities.⁶6. Celik H, Lagro-Janssen TA, Widdershoven GG, et al. Bringing gender sensitivity into healthcare practice: a systematic review. Patient Educ Couns. 2011;84:143-9.^,99. Crespí-Lloréns N, Hernández-Aguado I, Chilet-Rosell E. Have policies tackled gender inequalities in health? A scoping review. Int J Environ Res Public Health. 2021;18:327. In addition, different groups have been organized to work towards the reduction of gender inequities. Initiatives at the global level are conducting advocacy activities which could shape a new feminist public health agenda advocating the reduction of health inequities through the promotion of action. Among them, we highlight Global Health 50/50, which “works to advance action and accountability for gender equality in global health”; the Lancet Commission on Gender and Global Health that resulted from a “collective and strategic understanding of the need to mobilise individuals and institutions to redress imbalances in the gender-health relationship, producing a politically informed, globally relevant, and intersectional feminist strategy for structural change in global health”; the International Gender and COVID-19 Working Group whose objective is “to better understand and address the gendered effects of COVID-19 and government responses”; and the Gender and COVID-19 collaborative research agenda setting which aims “to support policy and programming-relevant research and accountability and identify a shared and prioritized research agenda and framework for evidence informed action to address gender and intersectionality in the global health and intersectoral COVID-19 response”.

This general picture suggests that academic and institutional research on gender and health remains essential, but that we need to shift the focus towards action and delve into the Beijing Platform for Action. More than 30 years ago, the Beijing Platform prioritised gender mainstreaming (strategy for making women's as well as men's concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and societal spheres). Policy makers and practitioners should debate whether this has succeeded or failed. Scientific literature suggests that the large body of evidence generated over the last decades regarding the influence of sex and gender on health and disease is underutilised in the design, implementation and evaluation of policies. On the basis of the numerous reports and scientific publications, discussions, reflections and recommendations pointing to gender inequities in health, we must design, implement and evaluate interventions, programs and policies which address gender health inequities. When doing this, we must consider that these inequities especially affect women worldwide, but also men. A key step towards effective policy-making lies in the design of tools that are easily applicable when considering the diverse decisions that affect gender equity. An example of this is to provide ready-to-use protocols to facilitate the incorporation of gender differences into clinical preventive, diagnostic and therapeutic decisions by a gender aware workforce in the health care setting.¹³13. Marcos-Marcos J, Gasch-Gallén A, Mateos JT, et al. Advancing gender equ(al)ity, lifting men's health: dealing with the spirit of our time. J Epidemiol Community Health. 2021;75:100-4. In the area of health policy formulation and in the design of public health programmes, the use of regulation that would require each step to incorporate equity in all its dimensions could make a significant difference. It should be a requirement to incorporate equity in general and gender equity in particular throughout the decision-making process, from the initial setting of priorities for action to the design of every public health programme.

No doubt, that it is necessary to continue working on the dissemination of actions that addresses the causes of gender-based inequities. However, public health researchers should always keep in mind, when considering possible research questions, what public health practice needs to do to address gender inequities.

Finally, let us not forget that gender is embedded within and across organisations, systemic structures and institutional norms.¹⁵15. Tannenbaum C, Ellis RP, Eyssel F, et al. Sex and gender analysis improves science and engineering. Nature. 2019;575:137-46. We need a feminist agenda that challenges structural and social power inequities in order to increase the gender equity in health.

Acknowledgement

The authors thank Jessica Gorlin for language editing.

References

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