Despite enjoying a longer life expectancy, women suffer more than men from a large host of non-fatal, disabling physical and mental illnesses and are generally expected to live fewer years in good health. Gender equality is increasingly on the agenda of the EU, and policies to advance towards equality are being implemented at all levels. Nevertheless, there is little evidence on how these policies are effective at reducing gender inequalities in health.

Main findings

Gender inequalities in health are larger in countries with policies less oriented towards gender equality
In most high-income countries women have poorer health than men in spite of the fact that they live longer. Policies that promote equality between men and women can partly bridge this gender gap.
We performed a systematic review showing initial evidence that policies that promote gender equity, reduce gender inequalities and improve women's health (1). We then classified European countries according to their family policy model and carried out 3 studies that compared men and women's self-perceived health (2), the mental health of working men and women (3) and the relationship between employment and family burden and self-rated and mental health (4) in the different family policy models.
Figure 12

In traditional (Southern and Central) and contradictory countries women are more likely to report poorer health than men. This is particularly the case for Southern countries (2). Among wage earners, and across different social classes, gender inequalities in mental health are more widespread and pronounced in market-oriented countries than in countries with other economic systems (3). The burden of combining employment and family demands seems especially harmful for the self-rated and mental health of women in traditional countries and men in market oriented countries (4).

Lone mothers' health in Spain

Lone mothers are a vulnerable group at greater risk of poverty and unemployment even in rich countries. We analysed two Spanish National Health Surveys, 2003 and 2011, and found that lone mothers presented poorer self rated health, mental health and health-related behaviours than couple mothers. Manual class lone mothers were particularly disadvantaged. Inequalities between lone and couple mothers did not change along the period. In a country like Spain, where a traditional family model with insufficient family support policies for mothers exists, socio-economic assets are key to determining access to resources producing health inequalities. This could particularly affect Spanish lone mothers (5).


Parental leave and gendered time use in Sweden and Spain

Gender equality policies influence gender inequalities in health

Time allocation is a highly gendered process, and division of work is an important factor in gender equality. Studies have found that an unequal division of work is related to low levels of well-being, particularly among women. By using Multinational Time Use Study data from Sweden and Spain taken in 1990, 2000 and 2010, we observed that changes in leave policies involving the introduction of or increases in exclusive paternal leave were followed by reductions in time use inequality between mothers and fathers. Our conclusion is that family policies that support gender equality through earning replacement, parental leave for both parents with universal coverage, and working time flexibility to balance family demands contribute to equalising time use between genders (6).

(1). Borrell C, Palència L, Muntaner C, et al. Influence of macrosocial policies on women's health and gender inequalities in health. Epidemiol Rev. 2014; 36:31-48.

(2). Palència L, Malmusi D, De Moortel D, et al. The influence of gender equality policies on gender inequalities in health in Europe. Soc Sci Med. 2014; 117:25-33.

(3). De Moortel D, Palència L, Artazcoz L, et al. Neo-Marxian social class inequalities in the mental well-being of employed men and women: the role of European welfare regimes Soc Sci Med. 2015; 128:188-200.

(4). Artazcoz L, Cortès I, Puig-Barrachina V, et al. Combining employment and family in Europe: the role of family policies in health. Eur J Public Health. 2014; 24:649-55.

(5). Trujillo-Alemán S, Pérez G, Borrell C. Health inequalities between lone and couple mothers in Spain, 2003 and 2011. Forthcoming. PPT.

(6). Hagqvist E, Pérez G, Trujillo-Alemán S, et al. Are changes in family-friendly policies related to gendered divisions of time use? A study of Spain and Sweden, 1990-2010. Forthcoming. PPT.

Public services for disabled people can improve the health of family caregivers
The adverse effects of family caregiving on physical and mental health are well documented. In Spain, this burden is concentrated among women, and mostly women of lower socio-economic status. The Dependence Act, passed in 2006, advanced social rights by declaring the universal nature of social services and recognising the subjective right of dependent persons to receive an economic contribution for family caregivers and a number of services at home or in care centres. Implementation of this plan has been limited by budgetary constraints, particularly following austerity cuts in 2012.
Using data from the Spanish National Health Survey 2006 and 2012, we compared the mental health and self-rated general health of the cohabitants of a disabled person who were responsible of their care, and non-caregivers (7). We used Concept Mapping to gather views of informal caregivers and primary healthcare professionals on how the Act had influenced the caregivers' quality of life (8).
Figure 13
Between 2006 and 2012, the health of family caregivers of both sexes improved more than that of non-caregivers (7). Concept mapping showed that the Act provided caregivers with the possibility of sharing the burden of care and reducing its physical, mental and social consequences while continuing to fulfil their responsibilities to the dependent person. Nonetheless, implementation problems, delays, budget shortfalls and austerity cuts in services and benefits also negatively affected caregivers (8).

How to resist austerity: the case of the Gender Budgeting strategy in Andalusia

As a political response to the current economic crisis, significant public policy budget cuts have been implemented while gender equality policies have been downgraded. An example of policy that has resisted austerity is the gender budgetary strategy in Andalusia. To understand why and how, we conducted a theory-driven explanatory case study. We interviewed politicians, feminist academics and civil society members. The main reasons for the resilience of the strategy include a strong political commitment with a solid female leadership supported by the continuity of a Social Democratic government, as well as several mechanisms triggered by the previous context of institutionalisation of the strategy and the facility provided by its low maintenance cost (9).

(7). Salvador-Piedrafita M, Malmusi D, Borrell C.Time trends in health inequalities due to care in the context of the Spanish Dependency Law. Gaceta Sanitaria, 2016

(8). Salvador-Piedrafita M, Malmusi D, Mehdipanah R, et al. Views of informal caregivers and healthcare professionals on the effects of the Dependence Act on caregivers' quality of life: concept mapping. Forthcoming. PPT.

(9). Puig-Barrachina V, Ruiz M, Malmusi D, et al. How to resist austerity: the case of the Gender Budgeting strategy in Andalusia. Forthcoming. PPT.

The intersectionality perspective is important in health equity research and policy evaluation
Socio-economic position, gender, ethnicity and immigrant background are axes of social inequality that interact among each other in creating health inequalities. Thus the design of policies to tackle health inequalities and their evaluation need to take into account all these dimensions, as well as their intersections.
We have developed a quick guide for incorporating intersectionality in evaluation of policy impacts on health equity, including practical examples based on the experience in the project (10) Whenever possible, we have stratified our analyses by sex, socio-economic position, immigrant background and/or age.
The impacts of changing contexts and policies differ at the intersection of different axes of inequality. For example, through the economic crisis in Spain, poor mental health increased in middle-aged and manual social class men, but not in other groups (10), and in immigrant more than native men (11). Immigrant background and gender intersect and reinforce one another to produce inequalities in the labour market in Europe. These inequalities can affect factors such as the quality of work, health and safety risk or workplace discrimination (12,13). A qualitative study among domestic workers in the service voucher system in Belgium revealed that immigrant women are particularly vulnerable for poor work quality and work-related health and safety risks. Their negotiation power with clients could be hampered by their limited labour market opportunities or problems related to their residence permit (14).


Policy implications

Policies that support women's participation in the labour force and decrease their burden of care, such as increasing public services and support for families and entitlements for fathers, are related to lower levels of gender inequality in terms of health.

Public services and benefits for disabled and dependent people can reduce the burden placed on their family caregivers and hence improve their health.

The intersectionality perspective should be taken into account as a health equity audit in the design and evaluation of policies and reinforced in research on health inequalities.


Research team

Gender studies in SOPHIE were part of Work Package 5 (Cross-cutting evaluation of policy impacts on gender and migration-related health inequalities), which has been led by Carme Borrell and Davide Malmusi, Agència de Salut Pública de Barcelona.

Other partners involved were Mittuniversitet, Vrije Universiteit Brussel and CRICH-SMH.


Click to read the project conclusions in PDF, in

English Spanish Catalan


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