Women’s Health Research Paper

1.1    Demographic Imperatives

Substantial changes  in women’s  health  and  life expectancy have occurred over the past 100 years. At the beginning  of the  twentieth  century,  in much  of the Western industrialized world, life expectancy at birth for women was less than 50 years. Life expectancy at birth  for  women  in most  industrialized countries  is now well into the late 70s and  the early mid-80s, on average about  seven to eight years longer than  men. By age 65 and over, this gender gap narrows,  and by age  85, life expectancy  for  women  is very  close to men’s. Life expectancy  is increasing  in all countries. The  worldwide  birth  rate  is  slowing  down,  which means   that   the   proportion  of  older   women   will increase substantially as well as numbers.

Since most chronic diseases and disabilities occur in older women, in many respects women’s health is concerned  with older  women.  However,  in developing countries,  infectious  diseases and  maternal  mortality  remain  high relative  to those  of industrialized countries. Since most of the world’s women live in developing countries such as Asia, Africa, and Latin America, the impact of morbidity  and mortality  from these causes is significant  from  a global  perspective. Cultural  practices,  views about  health,  and  women’s economic and social roles also greatly influence their physical  and  psycholsocial  health.  Since women live longer than men in most parts of the world, an array of poorly  understood cultural,   social,  and  behavioral consequences follow upon those changes. The increasing interconnectedness of the world by telecommunications and  faster  travel  means  that  women’s traditional  roles   may   be   rapidly   influenced   and changed dramatically by the alternatives  presented  to women through these channels. It is well documented that  education  for women can improve  their  health, increase  women’s  reproductive autonomy,  and  increase women’s life expectancy. The Global Burden of Disease report (Murray and Lopez 1998) has projected a decline  in death  from  maternal  mortality  and  an increase in noncommunicable diseases in women from 28.1 million death (1990) to 49.7 million in 2020. These changes are primarily due to reductions  in early death in infancy,  childhood,  or  in young  adulthood from infectious diseases and improved  prenatal  care.

2.    Socioeconomic Factors And Women’s Health

2.1    Women’s Socioeconomic Status

Worldwide, women’s incomes are lower, and they are less educated  than  men, limiting their ability to meet personal  and  family  economic  and  social  demands (UN 1995). In most of the world, women have primary responsibility  for  childcare  and  for  maintaining the household  (Haw 1995). Most  women work  either as employees or in subsistence agriculture as providers of food and shelter. In 1994, approximately 45 percent of the world’s women aged 15–64 were economically active (International Labor  Organization 1994) outside the home. The percentage  of households  headed only by women in Western Europe  increased from 24 percent  in 1980 to  31 percent  in some  areas  of the world,   it  now  exceeds  50  percent.   In  Africa,   60 percent  of rural  women  live below the  poverty  line (Haw 1995). Total  social and  economic demands  on women are therefore  often higher than  for men, and their ability to cope with these demands  is often constrained by  their  socially  defined  roles,  creating psychological as well as social conflicts. For example, women’s  family  roles  as primary  parent  may  be in conflict  with the need to earn  a living. Some industrialized  countries  in Scandinavia  and  Europe  offer flexible work policies, maternal  and family leave, but this is far from being the rule.

2.2    Women’s Health And Low Socioeconomic Status (SES)

SES is inextricably linked with poor health across the life span in both men and women. The effects of SES on women’s health compared to men’s health have not been well studied. Health effects of SES in women are likely  to  be  confounded by  marital   status  and  by spousal  income.  Women  who  are  not  married  are often of lower SES and women who are single heads of households  are almost universally of lower SES than women who are married. Thus, it is difficult to separate the effects on health of women’s social class from the effects of their  spouse’s social class. Most  infectious and chronic diseases are more prevalent  in women of lower socioeconomic  status  than  in women of higher SES. In the United States in 1997 among women aged 65 and  over, 12 percent  of white women,  27 percent of  African   American   women,   and   26  percent   of Hispanic  women were living below the Federal  poverty line (US DHHS  1999).

3.    Medical Care

Medical care is a factor  in women’s health  in several ways:  (a)  access  to  care  is more  limited  for  many women  because  of their  lower  economic  status,  (b) treatment of disease in women may be characterized by less aggressive follow up or by differential  lack of recognition of the disease in women compared to men, (c)  knowledge  about   the  efficacy  of  treatments  in women  is limited  by  the  past  lack  of  clinical  trails including women. Federal policies now require inclusion  of women  in medical  research  in many  developed countries. Women in developed countries use more medical care services than men and are the major decision makers for healthcare utilization for their families.  In  developing  countries,  medical  care  is a more  limited  resource  and  so may  be preferentially available to men. Reproductive health policies in many developed and developing countries restrict the rights of women to use contraceptives or to seek abortion for unwanted pregnancies. Prenatal  care is limited as well, leading to higher maternal mortality rates in women of lower SES and in less affluent countries. Education of women in developing countries has been shown to reduce  the  birthrate and  increase  the  use  of  contraceptive  measures (World Health  Report  2000).

4.    Cultural And Ethnic Factors In Women’s Health

Being a member  of an  ethnic  group  that  is not  the dominant culture in a country is often associated with a higher  risk of disease and  death.  This happens  at least in part because of the lower SES and ethnic discrimination often  associated  with immigration  or minority  status.  In some instances,  cultural  or ethnic factors  may be protective  if traditional culture  provides  extensive  social  support   and  networks  or  includes better health or dietary practices than the dominant culture. In many cultures, women are denied education,  employment,  and basic human  rights, and immigration   may  offer  the  opportunity to  improve their circumstances. However, women from more traditional societies may be more dependent  on their male partners, and immigration  may result in greater isolation  and substantial stress related to cultural dissonance   of  their  expected  role  and  the  role  of women   in  the  dominant  society  (Carballo  et  al. 1996).

4.1    Culture And Healthcare

Immigrant and  minority  women  usually  face economic, legal, linguistic, and cultural  barriers  in obtaining healthcare. The higher vulnerability  of immigrant and minority women to sexual abuse and violence increases  their  risk for sexually transmitted  diseases (STDs)   and   posttraumatic  stress  disorders;   issues which are rarely addressed in the healthcare settings in which these women find themselves. Even if a healthcare provider  is sensitive to these issues, women may be reluctant  to reveal what has happened due to fear and cultural  taboos.

4.2    Ethnicity

The  social  environment encountered  by  women  of color  may  account  for  a  substantial part  of  ethnic differences in health. For example, Cooper et al. 1999) have described the higher rates of hypertension in African  Americans   compared   to  whites  as  arising from  their  interaction with  the  social  environment. Cross-national comparisons of Jamaicans and African Americans  have shown that  life expectancy  amongst Jamaicans  is six years longer than African Americans (74 compared  to 70). African American women are at higher risk of cardiovascular diseases and hypertensive diseases. Obesity in African American women is consistently  over 50 percent.  The prevalence of most genetic factors  is relatively low and  none  have been identified that contribute significantly to ethnic differences in health.

5.    Psychosocial Factors

Some social and psychological factors significantly contribute to women’s health status  either directly as risk factors for disease, or indirectly by creating vulnerability to disease. Higher levels of social support have often  been linked  to better  health  outcomes  in both men and women. Social support  may modify the effects of other  variables  upon  the  risk  of coronary heart  disease. This may occur because social support may directly reduce reactivity to acute stressors, or by modifying behavioral  risk factors. Social support  may be  an  important factor   in  buffering  the  effects  of stressors on cardiovascular diseases and blood pressure. Women may respond differently to social support than  men,  or  may  access  different  kinds  of  social support.

Social isolation  has been linked to a higher risk of all-cause  and  cardiovascular mortality  rates  in both men and  women (Kaplan  and  Salonen  1988). Social isolation may be more common in older women, although this  issue  has  not  been  studied  globally. Certainly, poorer survival among men leads to a disproportionate number of older women living alone. In  the  United   States  in  1990,  35.3  percent  of  all women  aged  60 + were  living  alone  (Casper   and Barnett  2000). In countries where the sex difference in survival is greater, social isolation  may be greater for women in old age. Social isolation  in women is also linked to poorer  SES.

5.1    Psychological Factors

Gender  differences in the  influence  of traits  such as hostility and anxiety on health have not been examined extensively. Matthews  and  Owens (1998) found  that anger  suppression  and  hostile  attitudes were associated  with  higher  levels of carotid  atherosclerosis  in middle-aged women. Knox et al. (1998) reported  that coronary  heart disease was more prevalent  in women with  higher  levels of hostility.  This  association  was modified by the presence of social support.

5.2    Health Behaviors And Practices In Women

Health  behaviors  such as preventive  mammography screening or vaccinations  and lifestyle factors such as smoking  or  obesity  or  exercise are important determinants  of  health  in  women.  According  to  a  1998 survey of health  behaviors,  about  25 percent  of US women  aged  55 +   are  physically  inactive  and  this number  increases with age. Obesity is around 50 percent for African  American  women.  Smoking  prevalence has declined, but about  15 percent of women in the 55 +  age group  still smoke.  Behavior  or lifestyle factors also are associated with compliance with treatment for existing disease. For example, a study of adherence   to  cholesterol   guidelines  among  women with heart disease revealed that older women, African American women, and married women were less likely to use lipid-lowering medications. Women  who exercised, did not smoke, and drank moderate  amounts of alcohol  were more  likely to use lipid-lowering  medications.  In  the  United   States  in  1997,  the  median percent of women who reported they had had a mammogram in the past year was 73.7 percent (range: 56.5–83.6 percent)  85 percent  had  a  cervical  smear and 66.4 percent had both a clinical breast exam and a mammogram. Screening behavior  may increase with age as perceived risk increases. Women aged 55 + tend to seek both breast and cervical screening more often than younger women do. Acculturation and ethnicity also   can   affect   health   behaviors:   Latin-American women who are less acculturated tend to smoke and drink  less, exercise less, but  are  more  often  obese. Similar   patterns    are   seen   for   African   American women.

5.3    Violence Against Women

Violence against women, including rape and domestic assault,  has also become a worldwide  concern  and  a public  health  issue. Violence is related  to  the  lower social  and  economic  status  of women  compared  to men. The World Health  Organization (1996) has reported  that the prevalence of physical abuse against women ranges from 20 percent to 50 percent based on 40 studies  covering  24 countries  on four  continents. Rape and other forms of violence co-occur frequently. As  well  as  having  immediate   and  lasting  physical health effects, such occurrences can affect women’s psychological well-being; including self-esteem, poorer perceived health, obsessive disorders, eating problems, difficult interpersonal relationships and depression (Russo and Denious  1997).

6.    Menopause

Although menopause  has been more of a concern  in developed  countries,  as  maternal  mortality  declines and life expectancy increases in the developing world, the rate of growth in numbers of postmenopausal women is projected to increase. At this time, approximately 25 million women worldwide pass through menopause  every year. By the year 2030, there will be 1.2 billion menopausal and postmenopausal women, with an added 47 million new entrants  each year (Hill 1996). By the decade 2020–2030, there may be nearly 5  million  women  reaching  age  50  in  sub-Saharan Africa, over 7 million in India  and over 10 million in China.  In the future,  the vast majority  of postmenopausal   women  will  not  be  European  in  ethnicity. However, competing risks from the AIDS epidemic in Africa  may  well attenuate the  numbers   of  women reaching  middle  age.  As  women  age,  their  overall mortality  rates and cardiovascular or cancer mortality rates  tend  to converge with men’s rates,  but  do not generally  exceed  them.   This  convergence   is  often attributed to declining estrogen levels in women. The menopause  is also accompanied by a number of other changes in both physical and mental health in women and by changes in social and cultural  roles played by women.

Much of the menopause research had included only women of European background who are urban  and affluent  and  relatively  healthy  (Kaufert 1996). In  a number of cultures, menopause  frees women from the threat of pregnancy and may even increase their status. Symptoms of menopause  may vary by culture as well. The  most  consistently  reported   symptoms  are  hot flushes, ranging from nearly 60 percent in an affluent European  sample   to   seven   percent   in   Karachi. Reports  of these symptoms are substantially lower in Japanese   women  (Lock  1998)  compared   to  US  or Canadian women. As well, symptoms associated  with menopause  by Japanese women are very different and may  be  more  related  to  aging  in  general  than  to menopause  per se. Menopause is often portrayed as a catalytic   or  even  catastrophic  event  for  women’s health.  For  example,  the  increase  in cardiovascular disease seen in women after  menopause  is primarily attributed to  decrease  in  estrogen  levels. However, other diseases such as breast or colorectal cancer, and dementia, also increase more rapidly after menopause. This fact is not  consistent  with the view that  menopause  is the  major  reason  for  decline in the  health status   of  women.  If  she  lives  long  enough,   every women  undergoes  menopause,  but  most  women  do not become ill or dysfunctional after menopause.  The great variations  in cultural and socioeconomic factors influencing  health  status  among  women also suggest that the effects of biological menopause  on health are no doubt  contributory, but do no solely determine an older women’s health status.  Symptoms of the menopause vary across cultures, again suggesting social and cultural  influences on the experience and importance of menopause  in health.

7.    Disability And Aging

Women  in  areas  of  the  world  other  than  the  US and Europe  more frequently  suffer from lifelong nutritional  deprivation, chronic and repeated  exposures to infectious diseases, and poorer access to healthcare. Their  reproductive experience  is also  very different, involving multiple  births,  possibly  longer  periods  of breast feeding, and greater exposures to sexually transmitted diseases. Older women in the non-European world more often face widowhood,  divorce, abandonment, and poverty, and may carry the burden of caring  for the elderly and  grandchildren. Women spend  a greater  proportion of their  older  years with limitations in physical activity than do men with activities of daily living (ADLS) and instrumental activities of daily living (IADLS).  The need for caregivers providing assistance with ADLS or IADLS also increases in women with age at a greater rate than it does for men. The percentage  increase with age of women with unmet assistance needs is greater than for men, reflecting  their  greater  longevity  but  also their higher  levels of  disability  (US  DHHS   1999).  Such factors have a substantial social and economic impact upon the families of these older women.

8.    Conclusions

The global response to the growing imperative of women’s health  in developed  countries  has included national  policies which provide for increased research funding, establishment of wider availability of clinical care  programs targeting   women,  and  increased  allocation  in the private  sector to treatments targeting women’s  diseases.  Many   countries   and  the  World Health  Organization have  established  a  number  of centers  targeting  women’s health.  Although women around the world often live longer and are healthier at younger  ages  than  men,  this  longevity  is often  accompanied  by greater  levels of disability  and  health problems related to women’s lower SES and restrictive traditional roles. In the most  economically  deprived areas of the world, women’s lower status places them at higher risk of death, female infanticide, genital mutilation, socially sanctioned  murder  or suicide (of unwanted wives, for example), unwanted pregnancies, and sexually transmitted diseases such as AIDS. Globally, womens’ health issues range from the subtle problems  of menopause  to the most glaring issues of outright  violence and economic and social injustice.

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