Health Psychology. Michael Murray

      Figure 4.5 Under-5 mortality gradients for sub-Saharan Africa plotted against asset quintile. The area under each line represents the individual country rates. Quintile 1 has the least assets, quintile 5 the most

      Source: Marks (2004)

      An interesting set of relationships was observed between the U5MRs, literacy and resources (Marks, 2004). The U5MRs in 44 countries were positively correlated with female illiteracy rates and the proportion of households using bush, field or traditional pit latrines, and negatively correlated with the proportion of households having piped domestic water, national health service expenditure, the number of doctors per 100,000 people, the number of nurses per 100,000 people and immunization rates.

      The most important predictors of infant survival are educational and environmental. The most effective long-term structural interventions to combat inequality are to improve the educational opportunities for women and to improve the supply of drinking water. High literacy among mothers and access to water supplies and toilets are highly associated with low infant mortality. High numbers of doctors and nurses, immunization rates and health service expenditure are associated with lower mortality rates, but these health service variables are less influential, statistically speaking, than literacy, domestic water and sanitation. The latter provide the foundations of good health, while health services are the bricks and mortar.

      Gender

      Significant differences exist in health outcomes between men and women. Attitudes have changed a little over the last 100 years. A medical textbook from the nineteenth century stated: ‘child-bearing is essentially necessary to the physical health and long life, the mental happiness, the development of the affections and whole character of women. Woman exists for the sake of the womb’ (Holbrook, 1880: 13–14; cited in Gallant et al., 1997).

      In industrialized societies men die earlier than women, but women generally have poorer health (Macintyre and Hunt, 1997). Men in the USA suffer more severe chronic conditions, have higher death rates for all 15 leading causes of death, and die nearly seven years younger than women (Courtenay, 2000). Similar figures exist in the UK. In 1996, UK males had a life expectancy of 74.4 years compared with 79.7 years for females. This excess mortality of 5.3 years in males in 1996 increased over the course of the twentieth century from only 3.9 years in 1900–1910.

      Evidence suggests that from the Paleolithic period to the industrial revolution men lived longer than women, 40 years as compared to 35. Also, in less developed countries (e.g., India, Bangladesh, Nepal and Afghanistan) men still live longer than women (World Health Organization, 1989). To complicate the picture further, the health gradient is steeper for men than for women, while illness rates, treatment rates, absenteeism and prescription drug use are generally higher for women (Macintyre and Hunt, 1997). Women suffer more non-fatal chronic illnesses and more acute illnesses. They also make more visits to their family physicians and spend more time in hospital. Women suffer more from hypertension, kidney disease and autoimmune diseases such as rheumatoid arthritis and lupus (Litt, 1993). They also suffer twice the rate of depression. Men, on the other hand, have a shorter life expectancy, and suffer more injuries, suicides, homicides and heart disease.

      Psychosocial and lifestyle differences play a role in gender-linked health differences. In industrialized societies women suffer more from poverty, stress from relationships, childbirth, rape, domestic violence, sexual discrimination, lower status work, concern about weight and the strain of dividing attention between competing roles of parent and worker. Financial barriers may prevent women from engaging in healthier lifestyles and desirable behaviour change (O’Leary and Helgeson, 1997).

      Gender is a social construction, and social constructions of masculinity and femininity have relevance in particular to young men’s and young women’s health-seeking behaviour. The concept of ‘hegemonic masculinity’ as a locally dominant ideology of masculinity has been a focus of research (Connell, 2005). Hegemonic masculinity includes the demonstration of ‘machismo’ through the possession of physical and emotional strength, predatory heterosexuality, being a breadwinner and being unafraid of risk. Studies have focused on the health of men, why they suffer more from alcoholism and drug dependency, and why they are so reluctant to seek health from professionals. Gender-specific beliefs and behaviours are likely contributors to these differences (Courtenay, 2000). Men are more likely than women to adopt risky beliefs and behaviours, and less likely to engage in health-protective behaviours that are linked with longevity. Practices that undermine men’s health are used to signify masculinity and to negotiate power and status. Social and institutional structures often reinforce the social construction of men as the ‘stronger sex’.

      One of the cornerstones of masculinity is violence, especially violence against women. This violence cuts across culture and, with only a few exceptions, is a near-universal constant. Kaufman (1987) argues that violence by men against women is one corner of a triad of men’s violence. The other two corners are violence against other men and violence against self.

      Alternative constructions that subvert normative ideas of masculinity include non-drinking. A study of non-drinkers’ discourse examined the manner in which not drinking alcohol is construed in relation to the masculine identity. Three prominent discourses about non-drinking were revealed: (1) as something strange requiring explanation; (2) as simultaneously unsociable yet reflective of greater sociability; and (3) as something with greater negative social consequences for men than for women (Conroy and de Visser, 2013).

      Constructions of masculinity extend to young men’s help-seeking and health service use online. In one study, 28 young men took part in two online focus groups investigating understandings of health, help-seeking and health service use. Discourse analysis was used to explore the young men’s framing of health-related practices. Young men are interested in their health and construct their health practices as justified, while simultaneously maintaining masculine identities surrounding independence, autonomy and control over their bodies (Tyler and Williams, 2014).

      Ethnicity

      The health of minority ethnic groups is generally poorer than that of the majority of the population. This pattern has been consistently observed in the USA between African-Americans (‘blacks’) and Caucasian-Americans (‘whites’) for at least 150 years (Krieger, 1987). There has been an increase in income inequality in the USA that has been associated with a levelling-off or even a decline in the economic status of African-Americans. The gap in life expectancy between blacks and whites widened between 1980 and 1991 from 6.9 years to 8.3 years for males and from 5.6 years to 5.8 years for females (National Center for Health Statistics, 1994). Under the age of 70, cardiovascular disease, cancer and problems resulting in infant mortality account for 50% of