UNIVERSITY OF BEDFORDSHIRE FACULTY OF HEALTH AND SOCIAL SCIENCES MSc. PUBLIC HEALTH HEALTH AND SOCIAL CARE INEQUALITIES ESSAY ON HEALTH INEQUALITIES APRIL 2012 LECTURER: NASREEN ALI TABLE OF CONTENTS 1.0 INTRODUCTION…………………………… 3 2.0 DISCUSSION……………………………….. 5 2.1 Gender Behaviour and Access to Healthcare……. 5 2.2 Impact on Education and Work…………………… 6 2.3 Economic Status………………………………….. 8 2.4 Culture and Religious Influence………………….. 8 2.5 Policy and Political Development……………….. 10 2.6 Case Scenario…………………………………….. 10 3.0 CONCLUSION…………………………….. 11 REFERENCE………………………………….. 12 GENDERINFLUENCEAND REPRODUCTIVE HEALTH 1.0INTRODUCTION Oftentimes, it is assumed that gender differences in health are inevitable and constant, making various aspects of men and women’s health to be different. Over the years, the feminists have challenged the unfavourable effects of patriarchy on women’s health showing interest in the association between the discrepancies in women’s socio circumstances and their health (Annandale and Hunt, 2000). The liberal feminism’s assimilationist highlightedaccess to social roles and statuses among men as enhancing health status while the radical feminist emphasised the dominance of gender over other statuses in the creation of inequalities (Annandale, 1998). The rationale for this essay is that gendersignificantly impacts the opportunities and life chances offered to an individual, especially women, with regards to attitudes, expectations and roles, mainly in relation to education, employment, marriage, pregnancy and the care of children. These attitudes and roles often influence reproductive health. Having the knowledge of the peculiarity between sex and gender is important for guiding an appropriate examination of gender relations, roles, and identities and the association with reproductive health. The focus of this essay is to look at how gender affects other factors like education, work, economy and policy making in health and their subsequent influence on reproductive health. Sexrefers to the biological variances between women and men. It is concerned with the differences in physiology between them, whilegender describes thesocially constructed roles, behaviours and activities that are being considered appropriate for men and womenby a given society (Lauglo, 1999; WHO, 2000). Itrefers to the economic, social, political, and cultural qualities and opportunities related to being female and male. This definition of social construct varies among cultures, is learned and modifiable with time (Caro et al., 2003). Gender is anexpression of particular features and roles in a sociocultural context that arelinked with certain groups of people with reference to theirsex and sexuality, and it impacts their perception, thought and behaviour.Gender inequalities in health have been stated to be mostly socially produced rather than biologically given (Annandale and Hunt, 2000) andcan interrelate with other inequalities such as race, age, socio-economic class and ethnicity (Lauglo, 1999). According to United Nation (1995), reproductive health is defined as“a state of complete physical, mentaland social well-being and not merely the absence of disease orinfirmity, in all matters relating to the reproductive system andto its functions and processes”. It indicates individual’s capability of having a safe and satisfying sex life; gives thecapacity to reproduce and the autonomy todecide if, when, and how frequent in doing so. This shows the right of men and women to be informed and to haveaccess to safe, effective, affordable, and suitablefamily planning methods of their choice, in addition with other methods of theirchoice for fertility regulation which are lawful, andthe right of access to appropriate health-care services that willenable women to go safely through pregnancy and childbirth,and provide couples with the best chance of having a healthy baby (United Nation, 1995). Gender equality is the lack of discrimination, on the basis of individual’s sex, in chances, benefits, resource allocation and access to services (WHO, 1998). It affords equal enjoyment ofhuman rights, socially valued goods, opportunities, resources, and the benefits from development results to both men and women.Gender equityimplies fairness and justice in the sharing of benefits and responsibilities between men and women (WHO, 1998). This recognises the varying needs and power between men and women, and claimed that these differences should be identified and addressed in a manner that rectifies the imbalance between the sexes (Doyal, 2001). In ensuring fairness, there should be provision of measures to compensate forhistorical and social handicaps that prevent women and men from operating on a level playing field (Caro et al., 2003).The roles of womenand men and their relative power impact on their reproductive health and affect who does what in carryingout an activity, and who benefits.There is need to take into account both the differencesand the inequalities between women and men in programmeplanning, implementation, and evaluation and this is referred to as gender integration. The need for gender awareness in reproductive health has been emphasised because health inequalitiesare not only caused by the biological and genetic differences between men and women, but also result from the social disadvantages to which many women are subjected (Doyal, 2001; Lauglo, 1999), coupled with the fact that sexual and reproductive decision making is not carried out in a gender-neutral environment (Lauglo, 1999). Women and men make choices within the context of their homes and communities where gender roles, responsibilities, and status are defined. The way women approach the health system and the response of the sector to users and the public are also shaped by gender factors.Advancing gender equality, gender equity, and women empowerment; removingviolence against women; and ensuring women’s ability to control their own fertility are crucial components of the reproductive healthapproach (Lauglo, 1999).While gender affects the health of both men and women, there is a special emphasis on the health consequences of discrimination against women that exist in nearly every culture (UNDP, 1995). Powerful barriers including poverty, uneven power relationships between men and women, and lack of education have madehealth care inaccessible to millions of women around the world and thereby preventing them from attaining and maintaining the best possible reproductive health. 2.0 DISCUSSION 2.1GenderBehaviour and Access to Healthcare Reproductive health affect and is affected by the broadercontext of people’s lives, including their economic circumstances,education, employment, living conditions and family environment,social and gender relationships, and the political and legalstructures within which they live. Sexual and reproductivebehaviours are governed by complex biological, cultural andpsychosocial factors. The status of girls and women in society, and how they aretreated or mistreated in an environment that promotes the patriarchy roles of men, is a crucial determinant of theirreproductive health (UNFPA, 2011). The status of women and girls are greatly affected by their employment and educational opportunities which also influence how they control theirown lives, health and their fertility. Women bear the highest burden of reproductive healthproblems by being predisposed to complications from pregnancy andchildbirth; they also face risks in preventing unwanted pregnancy,suffer the complications of unsafe abortion, bear most of theburden of contraception, and are more exposed to contracting, andsuffering the complications of reproductive tract infections,particularly sexually transmitted diseases (UNFPA, 2011). Their social, educational, economic,culture and religion, and political disadvantages have adetrimental impact on their reproductive health. The patriarchy role accorded to men has made it difficult for women to achieve gender equality since they cannot attain sexual and reproductive health without the cooperation and participation of men (Lauglo, 1999; UNFPA, 2011). Thedecisions on the number and variety of sexual relationships, timing and frequency of sexual activity and use of contraceptives are usually made by men, sometimes through coercion or violence, andthe HIV/AIDS ‘feminisation’ is a pointer to the fact thatin many societies, women do not have the power to protect their own health (UNFPA, 2011).Men serving as community, political or religious leaders, often control access to reproductive health information and services, finances, transportation and other resources. As heads of government and policy makers, religious leaders and custodian of culture, as judges, heads of armies and other agencies of force, village heads, or indeed as husbands and fathers, men often wield enormous power over many aspects of women’s lives (Pantelides, 2002; Young and Kols, 2002).Ideas about manhood are extremely entrenched and from an early age, boys may be socialized into gender roles designed to keep men in power and in control, wherebymany grow up to believe that dominant behaviour towards girls and women is part of being a man (UNFPA, 2011). The patriarchal risk-taking and aggressive sexual behaviour on the part of young men are frequently applauded by peers and condoned by society. These stereotypes of masculinity and sexuality lead to constructed negative, high-risk and occasional harmful attitudes to both women and men, and erode possibilities of establishing satisfying, mutually respectful relationships. Gender inequalities not only affect women’s health butmay also limit their access to services, and many women continue to be underprivileged in provision of basic health care due to poverty and discrimination (Doyal, 2001). These financial obstacles have been mainly removed by the NHS in Britain. Nonetheless, evidence has shown that women are still treated by some doctors as less valuable than men coupled withthe unequal allocation of clinical resources while this can result in demeaning attitudes (Doyal, 1998; Raine, 2005). This gender bias is especially evident in the context of medical research, where studies revealed that women have beenhabitually excluded from studies for inappropriate reasons (Mastorianni, Faden and Federman, 1994). The gender roles and reproductive health are dependent on the social context which is influenced by the educational and occupational level, economic, culture and religion and political circumstances. These are highlighted further below. 2.2 Impact on Education and Work Many communities do not value education for female children and large numbers of women attain adulthood uneducated, especially in the developing countries (UNDP, 2006). Children, especially girls prematurely assume the responsibilities of an adult due to low educational level and are subsequently given into early marriages, hazardous labour or combat roles (UNICEF, 2006). The children whose mothers have no education are more likely to be affected by malnutrition and under-five mortality (UNFPA, 2002). Several norms with negative perceptions, gender-based beliefs that devalue women’s education and strong beliefs about the division of labour that places inequitable burdens on women are factorsthat pose as barriers to girl-child education (Abane, 2004). Likewise, the poor school enrolment and higher drop-out rates among boys can lead to their aggressiveness, destructive masculine norms and violence against women in compensating for their poor self-esteem (Osler et al., 2006). Therefore, with low level of education, many of the women may not have access to nor understand reproductive health information and could not make informed decision about their health. The low level of education could make women to be physically constrained and mostly employed and segregated in lower-paid, less secured and informal occupations. They are usually disposed to less wealth, property and poverty, whilst having higher responsibilities of work in the economy of ‘care’, ensuring reproduction and family’s well-being and security (Elson, 1993). In some societies, women are counted as less capable or unable and are often seen as repositories of men or family honour and the self-respect of the society (Fazio, 2004). The ability of some women to participate in formal (waged) labour market is also restricted by the responsibility of child care (Barriento et al., 2004). Furthermore, in situations where the women are in formal jobs, they are faced with multiple burden of job demand, the care of their families and their health. These trade-offs usually deepens the conflicts being faced by them in earning an income outside of the home and the primary duties of domestic work of care (Mansdotter et al., 2006). These burdens have impact on women’s health, both their occupational health, reproductive health and the consequences of inadequate rest and leisure. Despite this, women workers in such jobs are often loath to give up working if it means returning to the gender authority and patriarchal control of traditional family systems (Kabeer, 2002). Traditionally, women have been assigned to the main responsibility of seeing to their family needs and reproductive duty which limit them from taking part in the so-called ‘productive’ work. Although child care, care of the elderly, sexual role,food preparation and home maintenance are demanding tasks, butconsidered to be important to households and acknowledged as crucial to the society, yetwomen are usually unpaid (Lauglo, 1999). This is because householdworks are usually regarded as sites of consumption rather than producers of goods and services. 2.3 Economic Status Health research has identified occupation and education as indicators of socio-economic status (Annandale and Hunt, 2000) and also the socio-economic gradients is shallower in women than in men (Pugh and Moser 1990; Pugh et al. 1991; Koskinen and Martelin,1994) leading to increased poverty among the women. Men have been shown toconsiderably influence theirpartners’ reproductive health decision-making and use of health resources, so health practitioners have discovered poor performance inreproductive health programmes whenever there is failure to target men (Metha, 2002).Men can have a dominant role inreproductive health-related decisions and results and because of the prevalence of gender inequality in many societies, understanding their behaviour and views have been made important (Pantelides, 2002).Women’s health and their access to care are greatly influenced by men (Young and Kols, 2002), and all the above alluded to the fact that men wield financialand social power for their families.Many women are economically dependent on men who control family resources thereby putting the women in perpetual poverty, making them not to be able to pay for health care or transportation costs to health care facilities (Omondi, 2008). Economic factor has been identified as one of the preconditions for women to achieve reproductive health and gain control over their living conditions(Petchesky, 2000; Sims & Butter, 2000). However, structural obstacles that limit acquisition of social resources, for example, the structure of employment often make women to be economically dependent on men (Sen, 1994), and this may continually subject them to oppressive relations like gender based violence (Bowman, 2000). Women with higher socioeconomic status have been found to enjoy improved reproductive health outcomes (Wagner, 1998), as revealed in the fact that those in more economically developed countries tend to have better reproductive health than those of the less economically developed nations (Wang, 2007). 2.4Culture and Religious Influence Observing many religions and culture, it could be seen that the custodians of these beliefs and traditions are men, and they are the ones dictating compliances to the rules and norms. Many of the practices are based on gendered norms about women’s inferior social status, patriarchal family structures, honour, prestige, religious beliefs, and beliefs about men’s ownership of women who should be economically dependent on men, thereby making these gender disparities within society to cause violations of women’s rights (African Union, 2008). Some cultural norms about sexual and reproductive behaviours favour the disparities in the health status of women and men. The social value of woman that is based on her ability to bear children would make early, frequent and poorly spaced pregnancies to affect her health and nutrition (DANIDA, 2008). Power ofnegotiation of a woman in sexual relations with her husband may be weakenedin a community that permits polygamy or favours promiscuity for men, thereby putting her at higher risk of being infected with sexually transmitted diseases, including HIV/AIDS. Many cultural practices like management of menstrual hygiene, ritual segregation after birth including female genital mutilations targeted towards women are often harmful to their health. The roles of masculinity, femininity and sex are greatly defined during the adolescence as it tends to groom the male for independence, strength and authority but the females are taught to repress their abilities and capabilities(Sen and Östlin, 2007). These social norms and identities are internalized by young women and girls, and are transformed into cultural practices and individual actions of those who should protect girls and young women, for example, by parents who may encourage or ignore early coerced sex, permit their daughters to form relationships with much older men, or consent to their daughters being sold into sex work(Sen and Östlin, 2007). These subsequentlyproduce the situations in which some young and adult men (in the family or outside of it) sexually abuse girls or use physical violence against them, the preference by some adult men for younger female sexual partners, and the practice of sexual coercion bymany men and boys against girls (Barker, 2006). In interpretations, some religions agreed to equality of men and women, but others are profoundly patriarchal and find the challenge posed by gender equality to be exceedingly intimidating to their own age-old gratification of the fruits of masculinity power(Sen and Östlin, 2007) andattempts at holding on to such power have resultedinto turning down internationally agreed norms on gender equality, sexual and reproductive health and rights (Petchesky, 2003). The health and human rights of women and men and of young people have been greatly affected due to these attempts, for example reduction or non-availability of condoms even when they are the only known effective method to prevent HIV infection, and limitations to safe abortions even where they are legal and affect the health of women. 2.5 Policy and Political Development The political power and policy making of many nations are dominated by men who often assume that they are more equipped than women. Therefore, the women are treated as objects rather than subjects even in the families and communities, and this ismirrored in norms of behaviour, codes of conduct, and laws that exhibit their status as lower beings and second class citizens. Although there are some regions wheregreat gender inequality do not exist,nevertheless women usually have reduced access to political power and lower participation in political institutions from the local municipal council or village to the national parliament and the international arena (Sen and Östlin, 2007). While the above is true for women as a whole vis a vis men, there can be significant differences among women themselves based on age or lifecycle status, as well as on the basis of economic class, ethnicity and so on. Another dimension of women’s subordinate position is that men are more disposed to better education and jobs,greater wealth and political influence, and lesser behaviouralconstraints (Pantelides, 2002; Young and Kols, 2002). They thereby exercise power over women, deciding on their behalf concerning their health and reproduction, regulating and limiting their access to resources and personal agency (Young and Kols, 2002), and sanctioning and policing their behaviour through socially condoned violence or the threat of violence. Even though not all men exercise power over all women, but gender power relations are crisscrossed by age and lifecycle as well as the other social stratifiers such as economic class, race or ethnicity. Poor women and those who belong to subordinated racial or ethnic groups for instance tend to be near the bottom of the social order, bearing multiple burdens of poverty, work burdens, discrimination, violence and lower reproductive health status (Sen and Östlin, 2007). 2.6 Interplay between Gender, Religion and Politics: Case Scenario Authorities have stated that legislative and organisational activities should involve women as a social category of citizens (Berkovitch, 1999) and that the political development may empower women to organise and challenge the political systems and their position for the purpose of better reproductive health (Jaquette and Wolchik, 1998). The typical situation as it relates to impact gender inequality on reproductive health, even in developed countries, is what is being witnessed in the United State of America where the women has, over the years, been denied access to free contraception based on government policy and religious stand. The president in the 2010 Health Reform Law adopted the contraceptive-coverage rule to cover a wide range of preventive services intended to reduce unwanted pregnancies and related health problems among the women, including abortions. There were reports of women and girls being denied contraception because of religious affiliations and some had suffered severe consequences as a result. The government policy requires almost all employers who provide health insurance to provide coverage for women’s contraceptives without co-pays or deductibles. However, this move has been vehemently opposed on moral and religious ground by social conservatives, political and religious leaders most of which are men. They argued that the provision requiring organisations to offer free contraception on employee health plans is a war on religion. The feminists have described this argument as ploy to deprive women their rights (Morgan,2012). 3.0 CONCLUSION As part of several efforts, the inequalities in reproductive health can be handled by ensuring women empowerment, gender equality and equity, and gender mainstreaming (African Union, 2008). Gender equality and equity should be that which afford women equal access to social, economic, political and cultural opportunities, and not necessary equating men and women, but rather recognise and equally value their similarities and differences. It should involve redistribution of power and resources and fairness to both men and women. Gender mainstreamingisthe process, in all areas and at all levels, of evaluatingactions, legislation, policies and programmes and their consequences for women and men (UNESCO, 2003). 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