IJE Advance Access originally published online on February 28, 2005
International Journal of Epidemiology 2005 34(2):461-466; doi:10.1093/ije/dyh333
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Article |
Who is more likely to experience common disorders: men, women, or both equally? Lay perceptions in the West of Scotland
Medical Research Council Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow G12 8RZ, UK.
* Correspondence: E-mail: Sally{at}msoc.mrc.gla.ac.uk
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Abstract |
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Background Gender differences in health are commonly observed by epidemiologists. Little is known about lay beliefs concerning the gender patterning of common conditions.
Methods Using the West of Scotland Twenty-07 Study, we analysed responses to a question in a postal questionnaire asking whether respondents thought men or women (or both equally) were more likely to have heart disease, cancer, mental illness, and accidents, to be fit, and to live longer. This question was answered by 466 females and 353 males, then aged 25, 45, and 65 yr.
Results Responses were in general in accord with epidemiological findings, but females had significantly lower odds than males of perceiving men as being at greater risk of accidents and heart disease, and higher odds than males of perceiving women as being at greater risk of mental illness.
Conclusions There was a tendency for each gender to think risks were higher for their own sex than did the other gender. This observation needs further exploration, particularly in the light of the research showing ‘optimistic bias’ in relation to health, and research suggesting that socioeconomically disadvantaged people may be least likely to perceive socially structured health inequalities.
Keywords Lay epidemiology, gender, heart disease, cancer, Scotland
Accepted 9 August 2004
It is almost an article of faith among epidemiologists and health professionals that gender differences exist in patterns of health and illness. Gender differences in disease are so ubiquitous that epidemiologists routinely show health data separately for each gender, present age- and sex-standardized rate ratios, and/or control for gender in multivariate models.1 Perhaps surprisingly given the magnitude of gender differences, these differences are often treated as background givens rather than being the topic of research directly exploring the reasons for them.2
The conventional wisdom is that women live longer than men but experience more morbidity. Recent reviews have argued that this is an oversimplified picture and that gender differences in health vary by historical period, culture, stage of economic development, age group, and health measure.1,3–5 For example, women's longevity advantage tended to increase in developed countries in the mid-twentieth century, and increased fairly rapidly during the social dislocation following the fall of communism in Europe,6,7 but decreased in the Nordic countries in the late twentieth century.8 Whereas women tend to report higher rates of less serious physical and mental disorders, men tend to report higher rates of more serious disorders.9,10
However, in most developed countries, and certainly in the UK, women have longer life expectancy11,12 and more minor psychiatric morbidity than men,13 and men have higher (age-standardized) rates of heart disease and cancer14,15 and a higher incidence of accidents and rate of deaths from accidents11,14 than women. For some risk factors the male/female ratio varies with age: for example, women have a lower prevalence of high blood pressure and high cholesterol than men before the age of 55, but higher thereafter.11
There is an extensive literature, particularly in medical sociology, about lay perceptions of health16–22 and about the basis of self-ratings of health.23–27 There is a small amount of work on lay perceptions of the socioeconomic patterning of health18,20,28–31 and also on ‘lay epidemiology’, mainly in relation to heart disease32–35 and pain.36,37
There are some suggestions in the literature that lay people and health professionals may operate on stereotypes about the gender patterning of certain types of health problem or health behaviour. A qualitative study of middle-aged subjects from the West of Scotland found that coronary heart disease (CHD) was often perceived as a ‘male disease’ and women tended to be unmentioned or ‘invisible’ in discussions about heart disease (whether as people likely or unlikely to develop CHD).32 The authors argue that the emphasis on males in discussions of CHD may be linked to cultural representations, lay perceptions, medical research, health care provision, and health education policies that tend to focus on heart disease as a male disease.
This is supported by a study of physician's decisionmaking for cardiac diagnosis that found the gender of a ‘patient’ to be the most influential factor despite patients presenting identical symptoms, vital signs, and test results: 30-yr-old women with chest pain were much less likely than 30-yr-old-men to be given a cardiac diagnosis, much more likely to be given a psychiatric diagnosis, and around seven times more likely to be considered not to need medical treatment.5 This belief in heart disease as a male problem persists despite the fact that CHD is the leading cause of mortality among women in the UK38 (and in all European countries39). Contrary stereotypes may be applied to different conditions; a study comparing observer-assessed and self-assessed presence of symptoms of the common cold in a research setting found that although the clinicians thought that women were more likely to get colds, there was no gender difference in the directly observed or self-reported incidence of cold symptoms.40
In a study of pain, Bendelow found that both men and women thought that women were better able to cope with pain than men (although women were even more likely to think this than men).36,37 However, we know of virtually no literature that systematically examines lay perceptions of gender differences (or similarities) in the prevalence of health and illness. Do lay people have the same beliefs about gender differences in health and disease as epidemiologists and health professionals? And are there any differences between the genders in beliefs about sex differences? In this article we address these questions by examining lay beliefs about the relative likelihood of men and women experiencing common illnesses and health states.
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Design and methods |
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The analysis used data from the locality component of the West of Scotland Twenty-07 Study: ‘Health in the Community’.41 The Twenty-07 Study began in 1987 and is following three cohorts (born in 1932, 1952, and 1972), using home-based interviews and postal questionnaires, over 20 years. The objective of the study is to explore the social processes that produce or maintain social patterning in health, in particular, by gender, age, social class, ethnicity, family composition, and place of residence. The locality component of the study involved selecting two areas of Glasgow City with contrasting socioresidential characteristics—the northwest and the southwest—for relatively intensive study. The northwest is relatively advantaged, with better health indices, whereas the southwest is relatively disadvantaged, with worse health indices. Neither locality is at the extreme of health or social advantage in Glasgow.41,42
Data from the respondents in the locality sample have been gathered on four occasions so far, with face-to-face interviews in 1987, 1992, and 2000–3 and a postal survey in 1997. This analysis uses data from the 1997 postal survey, when individuals from the cohorts were 25, 45, and 65 years old. The sample size achieved for the survey was 819 (466 females and 353 males). The response rate to this postal survey was 76.7%.
To obtain information on lay epidemiology, respondents were asked, ‘Who do you think is more likely to have the following experiences (heart disease, being fit, cancer, mental illness, accidents/injuries, living longer): men or women, or both about the same?’ These conditions or experiences were selected because we also asked about perceptions of whether richer or poorer people were likely to experience them, and we were building on the work of Calnan20 in this regard. The epidemiological evidence about gender patterning in all of them (except being fitter) is fairly unequivocal; we were interested to know whether ‘being fit’ was seen as a gendered attribute. (We have also completed an analysis of the social class and neighbourhood patterning of beliefs among these subjects about socioeconomic differences in these conditions.31)
The responses to the question were cross-tabulated by gender, and chi-square statistics were used to determine significance. There was some item nonresponse, so the totals for the conditions can differ. (When all respondents with missing values are filtered out, the magnitude and significance of results remain the same.)
Logistic regression was used to determine the probability of males/females, different class groups, and the three cohorts perceiving women or men to be more likely to experience these conditions. The three category dependent variables were dichotomized. Cross-tabulations were used to determine which was the most common answer to a question; for example, women were seen as more likely to live longer or have mental illness, so perceiving women as being more likely to experience these was treated as the reference category and contrasted with ‘men’ and ‘both equally’ combined. The independent variables entered into the model were gender, cohort, and social class (based on the Registrar General's classification of occupational social class43 and grouped here into I/II/III non-manual (nm), III manual (m), and IV/V manual). Missing values were filtered out of the dataset before carrying out the regression. We tested for two-way interactions between cohort and gender. Only significant interactions were included, and these were investigated by carrying out the regression separately for males and females and separately for the three cohorts.
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Results |
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Bivariate analysis
The majority of respondents said that men and women were equally likely to have accidents, cancer, mental illness, and to be fitter, and that men were more likely to get heart disease and women to live longer. When one sex was considered more at risk than the other, men were thought more likely to have accidents and women to have cancer and mental illness (Table 1).
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There were significant differences between males and females in perceptions of which sex is more likely to experience accidents, cancer, heart disease, and mental illness. Thus, 48% of males compared with 37% of females said men were more likely to have accidents; 58% of females chose ‘both’, compared with 50% of males. Around two-thirds of both genders said they believed men and women were ‘equally likely’ to experience cancer; 12% of males compared with 3% of females said that men were more likely to have cancer, and 30% of females compared with 24% of males said that women were. Although the gender differences in perceptions of ‘fitness’ were not statistically significant, there was a trend towards males thinking that men were fitter and females thinking women were (19% of males thought men were fitter compared with 13% of females). For heart disease, there was a striking gender difference, 79% of males saying men were more likely to get heart disease compared with only 59% of females; 19% more females than males chose ‘both equally’. There were no gender differences in the assessment of sex difference in longevity, 87.5% of all respondents saying women lived longer. Compared with 18% of males, 31% of females believed women were more likely to suffer from mental illness, and 72% of men compared with 61% of women said ‘both equally’.
Multivariate analysis
Having controlled for cohort and social class and using male respondents as the reference category, odds ratios (ORs) for females were significantly lower for perceiving men as more likely to experience accidents or heart disease, and significantly higher for perceiving women as more likely to experience mental illness. There were no significant gender differences in perceptions of fitness or living longer; although those for experiencing cancer just missed conventional levels of significance, females had higher odds of thinking women more likely to experience cancer (P = 0.064) (Table 2).
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Compared with 25-yr-olds, 45-yr-olds had significantly higher odds of thinking men were more likely to experience accidents and women were more likely to live longer. The 45- and 65-yr-olds had significantly higher odds of perceiving women as fitter and as more likely to have mental illness. There were no significant differences between cohorts for cancer or heart disease.
In comparison with social classes I/II/IIInm, classes IIIm and IV/V had lower odds of perceiving men as more likely to experience heart disease and women as more likely to live longer or have mental illness. Social classes IIIm and IV/V had higher odds of perceiving women as fitter [although in the latter case this fell just outside conventional significance levels (P = 0.053)]. There were no significant class differences in perceptions of men and women experiencing accidents or cancer.
A significant interaction was found between cohort and gender for perceptions of living longer (Table 3). Regression carried out separately for males and females showed that 45-yr-old males had higher odds than 25- or 65-yr-old males of perceiving women as living longer. There were no significant differences for females by cohort. Regression carried out separately for the three cohorts showed no significant gender difference among the 25-yr-olds. Among 45-yr-olds, females had lower odds of perceiving women as being more likely to live longer than males (OR = 0.3), whereas among the 65-yr-olds, females had higher odds (OR = 2.2).
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Discussion |
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Many studies have investigated gender differences in health and potential explanations for these.10,44–46 In addition, many studies have investigated lay perceptions of health and illness,19–21,47 including gender differences in these,37 and several studies have examined ‘lay’, or ‘popular’, epidemiology.33,48 However, few studies have considered the lay epidemiology of gender differences in health and illness, that is, what members of the lay public think is the relative prevalence of common health experiences by gender. We have used a quantitative approach to investigate perceptions of whether men or women are more likely to experience certain health outcomes, and whether there are any gender differences in these perceptions, while controlling for potential confounding factors such as age and social class.
In general the lay epidemiology in this sample mirrored ‘professional’ epidemiology: males were considered more likely to have accidents and heart disease, and women much more likely to live longer and somewhat more likely to have cancer and mental illness. Most thought there was no gender difference in fitness, and there was little difference in the proportions suggesting women or men as fitter. The congruence between lay and professional epidemiology, although perhaps unsurprising, may of course mask divergence between lay and professional understandings of the meaning and aetiology of these conditions.
What is perhaps more novel and unexpected is that when there was a gender difference in attributions of relative likelihoods by gender, respondents tended to perceive the risks as being higher for their own sex than did respondents of the opposite sex. More males than females said men were at higher risk of accidents, cancer, heart disease, and mental illness; more females than males said women were more at risk of accidents, cancer, heart disease, and mental illness. This tendency was also evident for the one condition (fitness) posed in positive terms: males were more likely than females to say men were fitter, and females more likely than males to say women were fitter, although these gender differences did not reach statistical significance. Longevity was the only item to which this pattern did not apply.
These findings are consistent with those of Bendelow, whose subjects said they thought women were better at coping with pain: 66% of women thought this, compared with 33% men, and conversely 8% of women and 17% of men thought men coped better.36 The literature on personal risk assessments suggests a tendency to underestimate one's own risk of illness compared with one's peers; this is often referred to as ‘optimism bias’.49–51 Our findings, and those of Bendelow, suggest in contrast that what may be going on in response to these types of question is neither an optimistic nor negative bias for one's own gender but rather a bias towards thinking any health experience, whether positive or negative, is more probable for one's own sex than the opposite gender thinks.
This study has several limitations. The sample size is small, restricted to three single age cohorts, and located in two localities in the West of Scotland. We did not follow up the answers in the postal questionnaires with more qualitative approaches to find out the reasons or evidence for the responses to these questions. Asking which sex is more likely to have a health experience is not the same as asking how likely a person of a given sex is to have that experience: the fact that few respondents thought that women were more likely than men to develop heart disease does not mean that few respondents thought women were at risk of heart disease. People's estimates of the relative probability of health conditions by sex tells us nothing about their estimates of the probability of themselves experiencing these conditions.
Nevertheless, the magnitude and consistency of the observed gender differences in perceptions of which sex is most at risk of common disorders are striking. These findings contrast with those in relation to the socioeconomic patterning of disease, including findings from the same respondents, which suggest that those most disadvantaged by the socioeconomic gradient in health may be least likely to accept that structured health inequalities exist and that they personally are therefore at higher risk.18,20,28,30,31 The picture shown here is instead that each gender tends to think it is more likely to experience a range of conditions than the other gender thinks (with the exception of longevity). This implies that there is not a general pattern of assessing risks as lower among one's own group based perhaps on rejecting structural analyses of the patterning of health and attributing more importance to personal health behaviours and lifestyle choices,18,20,28 or on an optimistic bias. 49–51
We suggest that this topic needs further research on larger samples and across a range of sociocultural settings, in order both to enhance our basic understanding of lay perceptions of health and to improve health promotion messages directed at the public and professionals.
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Acknowledgments |
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All authors are supported by the UK Medical Research Council, which also funds the West of Scotland Twenty-07 Study. We are grateful to all the participants in the study and to the fieldworkers and survey staff who assisted with data collection. Carol Emslie provided helpful comments on earlier drafts, and she and Mildred Blaxter drew our attention to some of the relevant literature.
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