Tackling the gender dimension of health inequalities

Women on average live six-and-a-half years longer than men. The discrepancy comes down to differences in lifestyles between men and women, particularly concerning smoking and drinking.

The 2008-2011 National Action Plan to Reduce Health Inequalities has carried out important work in Finland over the last four years. This outlines proposals for strategic policy definitions and the most important measures to reduce health inequalities in the country.

A specific action plan on health inequalities was pursued because inequalities have persisted in Finland despite the efforts undertaken through health and social policy. Narrowing health gaps has been the objective of Finnish health policy since the 1980s. This objective has not been achieved, however, and the inequalities have in part even grown. These inequalities also have an important gender dimension, crosscutting and intersecting with the socio-economic factors in which they are rooted.

Health inequalities are a problem across the EU, too, often encompassing severe social and economic disparities between and within the member states.

In 2009 the EU Commission reported that throughout the community there is a social gradient in health status where people with lower education, a lower occupational class or lower income tend to die at a younger age and to have a higher prevalence of most types of health problems. The Commission stated that there is an important gender dimension to health inequalities and their determinants at the EU level, and that women in general live longer than men.

Between EU Member States, the Commission reported, there is a five-fold difference in deaths of babies under one year of age, a 14-year gap in life expectancy at birth for men and an eight-year gap for women. Large disparities in health are also found between regions, rural and urban areas and neighbourhoods.

In Finland, as elsewhere in the EU, smoking and excessive drinking remain stubborn factors responsible for the most persistent health inequalities.

"Alcohol is responsible for about 25% of the health inequalities between men and women. Both alcohol consumption and binge drinking are far more pronounced among men than among women," says Ismo Tuominen, Ministerial Counsellor at the MSAH. "Men die from alcohol use four times more often than women. The differences are to the detriment of men in terms of chronic harm and acute harm, in other words injuries and homicides."

The harmful effects of alcohol use can be prevented by limiting the availability of alcohol through taxation and restrictions concerning retail outlets and sales times.

"It is well known that, in terms of the population, limiting the availability of alcohol is by far the most effective method. It is entirely possible that the government's agreed tax increases and reform of the Alcohol Act will see a drop in figures for alcohol-related harm," says Tuominen.

One of the aims of the National Action Plan to Reduce Health Inequalities has been to cut alcohol consumption to the level it was in 2003 (9.4 litres of pure alcohol per capita) by the end of this year. This objective has not been quite reached, though consumption has dropped during the period of the programme from 10.5 litres to 10 litres

As a cause of health inequalities smoking is a killer roughly on a par with alcohol. Smoking is more common among men than women. In 2010 about 23% of men in Finland smoked on a daily basis, while for women the figure was 16%. But smoking among men has clearly declined over the years. In 1990 some 33% of men were daily smokers. Smoking among women, on the other hand, has remained the same or has sometimes even increased.

According to the Action Plan, smoking is highly polarised according to educational group at the moment. Only about ten per cent of all smokers fall into the most highly educated bracket. The Action Plan suggests the use of prohibitions on smoking as an automatic feature of people's everyday environments, something that has become more accepted throughout society.

Overall progress has been achieved concerning smoking. In addition to legislation restricting smoking, increased awareness of the impacts of smoking has seen a considerable drop in smoking over recent decades.

"This development involves an interesting observation. When the health dangers of smoking became widely known there was a marked drop in smoking among men. But smoking among women continued to increase over decades, at the same time that the tobacco industry marketed smoking as an aspect of women's liberation," says Tuominen.

There are also numerous other statistics that bluntly express the scope of health differences between men and women. Some 43% of men suffer from high blood pressure, a condition that affects only 29% of women. Men are more prone to coronary heart disease than women. Dietary differences between the genders are shown by the example that in 2009 over half of men and just under a third of women make little use of berries and fruit in their diet.

The Action Plan places much emphasis of the role of socio-economic factors in sustaining health inequalities. People with a higher level of education and stronger socio-economic position tend to fare better than others. The Action Plan notes that in recent decades there has been a general improvement in eating habits in Finland, with more people eating vegetables and fruit, and fewer dairy products. But it points out that people of good socio-economic standing tend to follow the recommended diet more commonly than others.

Cultural factors in the gender dimension of health inequalities help explain differences in matters such as drinking and smoking, but they are hard to influence.

"The health inequalities between men and women have narrowed, but the reason is that women nowadays drink and smoke more than, say, 40 years ago. Even in the 1970s women could not go to a restaurant alone, and only "women of ill repute" would smoke on the street. Nowadays there's practically nowhere else where you can smoke. Society's legal rules are also a reflection of culture, or more specifically a culture of disapproval or lack of disapproval," Tuominen muses.

The MSAH's administrative sector has recently closely studied the impacts of weak social and economic status on health inequalities. It is reported that concerning mortality differences lifestyle accounts for about a half of male and a third of female mortality. 

"From the perspective of the welfare of the population as a whole it would be justified to raise the high mortality among men as by far the greatest challenge of national equality policy," says Tuominen.

The current MSAH strategy states that Finland's large welfare and health inequalities between population groups and the genders cannot be eliminated purely by social and health care measures. The most effective way to reduce such inequalities is through the close collaboration between different administrative sectors of government.

In particular, it is important that work is carried out with children and the young to ensure that in the future health inequalities are smaller.

The Action Plan states that the roots of socio-economic health inequalities lie in childhood, because some children have to grow up in poor living conditions and environments. Factors detrimental to good health tend to concentrate around those with low social status, little education and low income.

The Action Plan points out that these are also passed on from one generation to the next.  It concludes by saying that health inequalities between social groups are not the result of some natural law, but the result of human activities and social decisions, and this means that they can also be reduced by social activities and decisions.

Ritva Kosonen and Mark Waller