Elsevier

Social Science & Medicine

Volume 62, Issue 4, February 2006, Pages 815-827
Social Science & Medicine

Cross-national variation of gender differences in adolescent subjective health in Europe and North America

https://doi.org/10.1016/j.socscimed.2005.06.047Get rights and content

Abstract

The cross-national consistency and variation of gender differences in subjective health complaints was examined in a sample of 125732 11- to 15-year-olds from 29 European and North American countries, participating in the WHO collaborative study ‘Health behaviour in school-aged children (HBSC) 1997/98’. Health complaints were measured with the Health Behaviour in School-aged Children Symptom Checklist. Gender differences in health complaints were analysed through multilevel logistic regression analysis. The results indicated a very robust pattern of increasing gender differences across age, with 15-year-old girls as a group at increased risk for health complaints across all countries. The magnitude of gender differences varied across countries, with some countries showing a consistently strong gender difference across age group and different health complaints, and other countries showing a consistently weak gender difference. The gender difference in health complaints was stronger in countries with a low gender development index score. The findings underscore the need to incorporate socio-contextual factors in the study of gender health inequalities during adolescence.

Introduction

One of the most well-established findings in health-related research is that women tend to report higher levels of health complaints than men do (Eriksen, Svendsrod, Ursin, & Ursin, 1998; Van-Wijk & Kolk, 1997; Verbrugge, 1985), but the magnitude of differences varies considerably across study populations (Lahelma, Martikainen, Rahkonen, & Silventoinen, 1999; MacIntyre, Hunt, & Sweeting, 1996; Sweeting, 1995; Sweeting & West, 2003). Comprehensive literature reviews have made a strong case for the notion that gender differences in health complaints can be observed for some groups, but not in other groups (MacIntyre et al., 1996; Sweeting, 1995). The observed variability of gender differences has stimulated a renewed interest in factors that moderate such differences. Rather than viewing gender differences as fixed, the question becomes: under what conditions are gender differences strong, and under what conditions are gender differences weak? In this paper we highlight conditions at the societal level as a strong source of variability in gender differences.

Attempts to explain gender differences have included factors at various levels of explanation, including genetic factors (Silberg et al., 1999), perceptual factors (Van-Wijk & Kolk, 1997), as well as structural factors related to the distribution of work and political power (Kawachi, Kennedy, Gupta, & Prothrow-Stith, 1999), and gender role socialisation. These factors offer scope for influences at several levels, including the societal level.

Although the notion of a ‘society and health’ perspective on gender differences is not new, relatively little is known about the degree to which national social, and cultural characteristics influence the magnitude of gender health inequalities. Work by the United Nations Development Program (UNDP, 1995) has revealed profound national differences in women's achievements and life opportunities as compared to men. Such differences indicate that the national level is a potentially important level for examining social moderating influences on gender differences in health.

The few studies to address cross-national variation in gender differences have revealed a complex pattern. In a large multisite cross-national sample of primary care attendees (Piccinelli & Simon, 1997), women reported a statistically significant higher level of somatic complaints than men in 11 of the 15 centres. However, in two of the remaining four centres, men showed the highest mean score, although not significantly higher than women.

Cross-national variability of gender differences has also been suggested in adolescent community samples. A cross-cultural study (Crijnen, Achenbach, & Verhulst, 1999) of the Child Behaviour Checklist Syndromes (Achenbach & McConaughy, 1987) involving adolescents from 12 nations, reported that gender differences in somatic complaints varied as a function of culture and age, with increasing cross-national variability in gender across age. For US adolescents there was virtually no gender difference. Similarly, a gender by country interaction was reported in recent study of adolescents from four European countries (Haugland, Wold, Stevenson, Aaroe, & Woynarowska, 2001), with the strongest gender difference shown by Polish adolescents, and the weakest gender difference shown by Scottish adolescents.

Previous reports of cross-national variation in gender differences are open to several interpretations. From a “society and health” perspective, the cross-national variation could reflect a moderating influence from national differences in the gender distribution of power and life opportunities. As a general hypothesis one would expect the gender differences to be smaller in countries with equal life opportunities for men and women compared to countries with unequal opportunities. From recent work it is well established that modern industrialised countries differ considerably in their distribution of power and life opportunities between men and women. However, none of the above-cited studies addressed the influences of social factors.

A second interpretation to be considered is that previous reports of cross-national variation reflect a so called ‘compositional’ effect (e.g. Diez-Roux, 2002). From pure chance one would expect gender differences to vary across samples. Such compositional effects could erroneously lead to conclusions about contextual variation in gender differences, when in fact the differences are due to individual level factors in several life domains, such as body image, school pressures, material living conditions, and social network variables. Previous studies have not been able to rule out such factors as likely explanations for the variability of gender differences.

The present study examined compositional and contextual sources of cross-national variation of gender differences in health complaints in young people. The study was undertaken as part of the collaborative study Health Behaviour in School-Aged Children (HBSC) 1997/98. In the present study our investigation was structured according to three main objectives: the first part address the amount of gender differences across countries and age groups. In the second part of the paper we examine compositional effects of individual level factors on cross-national variation in gender differences. In the last part of the article we present relationships between macro-level factors and gender differences.

Section snippets

Sample

Data were obtained from the large cross-national WHO collaborative study ‘Health Behaviour in School-aged Children 1997/98’ (Currie, 1998). The target populations for the HBSC study are 11-, 13-, and 15-year-old students. In the HBSC 1997/98 study, a total of 125 732 students from 29 countries and regions participated (see Table 1). As shown in Table 1, the sample consisted of adolescents from a culturally and economically diverse collection of countries.

The sample was obtained through a complex

Differential item functioning

Table 2 shows the results of a test for DIF by country, using a hierarchical blockwise logistic regression analysis with single items as the dependent variables. The first block included the main effect of total scale score (trait). In block 2, the main effect of country membership was entered. For each item the entry of country membership in block 2 accounted for items score beyond the scale score. This means that young people with the same scale score would respond somewhat differently

Discussion

The present study extends previous research on gender differences in several ways. First, by studying samples of young people from all over Europe and North America, the observed gender differences findings can with some confidence be generalised to adolescents from a large proportion of the worlds industrialised countries. Second, the comprehensive set of data enabled for a more powerful statistical approach to the issue of cross-national variation than has previously been possible with data

Acknowledgments

The authors would like to thank the following Principal Investigators of the Health Behaviour in School-Aged Children: A WHO Cross national Study (HBSC) 1997/98 for their contribution in the production of the paper: Wolfgang Dür (Austria), Lea Maes (Belgium-Flemish speaking), Danielle Piette (Belgium-French speaking), William Boyce (Canada), Ladislav Czemy (Czech Republic), Pernille Due/Bjørn Holstein (Denmark), Mary Hickman (England), Mai Maser (Estonia), Lasse Kannas (Finland), Christiane

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