Mind the [rural] gender health gap?  

While women in the UK are living longer than men, many are spending a greater proportion of their lives in ill-health and disability. Women make up 51% of the population yet they are often under-represented in the health and care system which has tended to focus less on women-specific issues (e.g. miscarriage, menopause) or how other conditions impact on women in different ways. On 20 July 2022, the Government published its first ever Women’s Health Strategy for England. Will this improve the way the health system listens to women and boost health outcomes for women and girls? And what might it mean for women and girls living in rural areas? Jessica Sellick investigates. ………………………………………………………………………………………………..

According to the World Health Organization (WHO), gender norms, socialisation, roles, differentials in power relations and control over resources all contribute to differences in vulnerabilities and susceptibilities to illness, how illness is experienced, health behaviours, access to and uptake of health services, treatment responses and health outcomes. In this context, gender can determine the health risks faced and taken. Similarly, sex can affect disease risk, progression and outcomes through genetic (e.g. function of X and Y chromosomes), cellular and physiological (including hormonal) pathways. 

Health gaps are differences in the prevalence of disease, health outcomes (both physical and mental), or access to healthcare across different groups (e.g., according to gender, ethnicity, socio-economic status). 

A male health gap is when women are generally healthier across their lives than men. Studies collated by MANUAL found Eastern European countries dominate, with Georgia having one of the largest male health gaps. The WHO, for example, found the mortality rate for males in Georgia was almost twice the rate of that for females. 

MANUAL examined the health gap by gender across 156 countries around the world. They indicated how, in many countries, while men often tend to be in positions of power, have more privilege and more wealth compared to women; this advantage does not necessarily translate into better health – indeed, men often experience poorer physical and mental health outcomes compared to women. Smoking, alcohol, and substance abuse; cultures that embrace stereotypical ideas of masculinity and patriarchy tend to score highly on male health gaps. 

Unexpectedly, the United Kingdom does not follow the trend of men being unhealthier throughout their lives – we have a female health gap, wherein women’s health is generally lower than men’s health. MANUAL has ranked the United Kingdom 12^th out of 156 countries for female health, revealing it has the largest female health gap in the G20.  

In the UK, women live, on average, for longer than men. In 2019, life expectancy at birth in England was 79.9 years for males and 83.6 years for females. However, the ‘mortality advantage’ that women have is offset by the fact that spend a greater share of their life in ill health. According to the Centre for Ageing Better, the proportion of women’s lives spent with disability increased from 21.2% to 26.7% between 2006-2008 and 2018-2020 (compared to 18.6% and 21.5% for men, respectively).The data also shows that, at 65 years of age, a woman living today can expect to spend less than half of her remaining years in good health (47% compared to 53% for men). 

Why is there a gender health gap in the UK? The underlying cause is often attributed to the health system being built by men for men. According to the Royal College of Obstetricians & Gynaecologists (RCOG), too often, women are struggling to get the right information they need about their health, to book routine appointments and to get their basic health needs met. Similarly, studies have found that in many areas of healthcare women experience poorer outcomes than their male counterparts. 

• Women are less likely to be diagnosed at the early stage of Alzheimer’s because they tend to have better verbal memories than men. 
• Women were found to be 13% less likely than men of the same age to receive life-saving drugs such as statins after a heart attack. Women are twice as likely as men to die in the 30 days after suffering a heart attack. 
• Women are underrepresented in clinical trials. There has been five times the amount of research into male erectile dysfunction (affecting 19% of the male population) than premenstrual syndrome (affecting 90% of the female population). 
• Women have been unable to obtain their choice of HRT medication leading some to experience migraines, severe back pain and hot flushes. In April and May 2022 this led the Government to issue Serious Shortage Protocols (SSPs) to restrict dispensing to 3-months’ supply of Oestrogel, Ovestin  and Premique Low Dose; and allow pharmacists to substitute appropriate HRT products without a new prescription.
• The All-Party Parliamentary Group on Menopause’s Inquiry assessing the impacts of menopause highlighted instances of women experiencing difficulties in getting a diagnosis and accessing HRT – and how they were being offered antidepressants, against guidelines.    
• It takes 8-years, on average, from onset of symptoms to receiving a diagnosis of endometriosis. Prior to receiving a diagnosis, 58% of patients had visited their GP more than 10 times; 21% had visited doctors in hospital 10 times or more; and 53% had been to A&E. 
• The prevalence of common mental health conditions is increasing in women. Young women in particular have been identified as a high-risk group, with over a quarter (26%) experiencing a common mental disorder – such as anxiety or depression – compared to 9.1% of young men.
• Office for National Statistics (ONS) data has shown that since 2012 suicides amongst females aged 10 to 24 years has increased. In 2019, it reached its highest level of 3.1 deaths per 100,000 females. However, in 2019, three-quarters of deaths registered as suicide were among men.  

Commentators describe how women’s health issues are likely to be misdiagnosed or dismissed by clinicians as something less critical. Similarly, many conditions are defined as medically benign and therefore not prioritised despite becoming life limiting for many women. This all leads to services which have not been designed with women or to meet their needs.  

Numerous reports have also highlighted situations where women have suffered harm as a result of poor healthcare. 

• The Paterson Inquiry Report found a breast surgeon, Ian Paterson, had subjected more than 1,000 patients to unnecessary and damaging operations over a 14-year period. 
• The First Do No Harm Report looked at patient reports of harm from three medical interventions. The report highlighted the suffering of patients, many of them women, and found the health system to be ‘disjointed, siloed, unresponsive and defensive’.
• An Independent Review of maternity services at the Shrewsbury and Telford Hospital NHS Trust found failures which may have led to the deaths of more than 200 babies at the Trust. Donna Ockenden, the author of the review, is now chairing a review of maternity services in Nottingham. 
• ‘Reading the Signals’, an independent investigation led by Dr Bill Kirkup on maternity and neonatal services in East Kent published in October 2022 found 45 of the 65 baby deaths that occurred during the review period could have had a different outcome, and how women were treated without compassion.   

What do we do about it? On 20 July 2022, the Government published its first ever Women’s Health Strategy for England. The Strategy was updated on 30 August 2022. The 10-year Strategy sets out how the Government will improve the way in which the health and care system listens to women’s voices, and boost health outcomes for women and girls. The Strategy takes a life course approach, focusing on understanding the changing health and care needs of women and girls from adolescence to later life.

A call for evidence received 110,123 public responses, and more than 400 written submissions from organisations and experts in health and care. The Government used these responses to shape the Strategy. The call for evidence also shaped the Vision for Women’s Health Strategy which was published in December 2021. This set out the findings of the consultation and identified the key themes and areas of focus. The themes were: 

• Women’s voices. 
• Healthcare policies and services. 
• Information and education. 
• Health in the workplace. 
• Research, evidence and data. 

The following priority areas relating to specific conditions or issues were also highlighted: 

• Menstrual health and gynaecological conditions. 
• Fertility, pregnancy, pregnancy loss and post-natal support. 
• The menopause. 
• Healthy ageing and long-term conditions. 
• Mental health. 
• The health impact of violence against women and girls. 

Professor Dame Lesley Regan was appointed as the Government’s first ever Women’s Health Ambassador on 17 June 2022. Building on the call for evidence, vision and the appointment of Professor Regan, the Strategy is aiming to:

• Provide £10 million for a breast screening programme, with 25 new mobile breast screening units targeted at areas with the greatest challenges in uptake and coverage. 
• Remove the additional barriers to IVF for female same-sex couples.
• Improve the provision and availability of IVF to tackle the postcode lottery. 
• Introduce a pregnancy loss scheme to recognise parents who have lost a child before 24 weeks. 
• Update the service specification for severe endometriosis. 

Further building on the Strategy, the Government has also committed to: 

• Transforming the NHS website so that it becomes the first port of call for women’s health information. 
• Encouraging the expansion of Women’s Health Hubs and other models of ‘one stop clinics’ that bring women’s services together. 
• Publishing a definition of ‘trauma informed practice’ to address barriers to accessing services. 
• Commissioning research by the National Institute for Health and Care Research (NIHR) into healthcare professionals experiences of listening to women in primary care. 
• Introducing specific teaching and assessments on women’s health in undergraduate curricula for all medical students from 2024-2025. 

All of this work builds upon existing work undertaken by the Government, including: 

• The establishment of a Maternity Disparities Taskforce to tackle disparities in outcomes and experiences of care for women and babies by improving access to pre-conception and maternity care for women from ethnic minority background and those living in the most deprived areas. 
• Investing £127 million to increase and support the maternity workforce and increase neonatal care capacity. 
• Setting up the UK Menopause Taskforce. 
• Reducing the cost of, and improving access to, HRT.  
• Banning virginity testing and hymenoplasty. 
• Enhancing women’s reproductive wellbeing in the workplace through the Health and Wellbeing Fund 2022-2025. 
• Banning the availability of Botox and cosmetic fillers to under 18s for cosmetic purposes and banning advertisements for cosmetic surgery that target under 18s. 
• Investing £302 million in the Family Hubs and Start for Life Programme. 
• Providing protection to people who experience domestic abuse through the Domestic Abuse Act 2021. 
• Abolishing the Tampon Tax, thus removing VAT from women’s sanitary products and providing free sanitary products in schools, colleges and hospitals.  

While many commentators have welcomed these developments and the Strategy, some have raised concerns around the lack of initiatives focused on ensuring health professionals listen to women. Some view the Government’s approach as being too silo focused rather than changing the culture of the entire health and care system and its workforce. Similarly, some argue that the Strategy does little to address the socio-economic barriers that some women face. The Strategy also has little to say about including women in decision making (e.g. data, research, leadership roles). 

Mind the rural gender gap? The NHS Constitution is founded on the principle of equal access to health care. The Constitution states that the NHS is available to all and that it has a ‘social duty to promote equality through the services it provides and to pay particular attention to groups or section of society where improvements in health and life expectancy are not keeping pace with the rest of the population’.  The Parliamentary Inquiry into Rural Health and Care and numerous other reports have all highlighted the unmet and growing health and care needs of people living in rural areas. And yet, there are no references to rurality in the Women’s Health Strategy for England. We already know that access to health care is more problematic for people living in rural areas (e.g. access to maternity care, primary care, secondary care) and that more needs to be done to tackle the wider determinants of health in a rural context (e.g. housing, education, employment, income). Similarly, we also know, more broadly, that the provision of public services is generally poorer in rural areas compared to urban areas. 

In March 2021 the WHO published six priorities for women and health worldwide. This was part of a recognition that women and girls face new and emerging challenges, and that the COVID-19 pandemic has exacerbated existing inequalities and disrupted access to health services. 

1. Ensuring essential health and support services for all women and girls, and prioritising women’s health needs in global research and trials. 
2. Elevating the position of women in the health and care workforce – ensuring they occupy health leadership roles and addressing gender pay gaps. 
3. Preventing and responding to violence against women. 
4. Ensuring quality sexual and reproductive health for all. 
5. Reducing noncommunicable diseases among women. 
6. Increasing women’s participation and leadership in science and public health. 

In the United States, the National Rural Health Association (NRHA) is calling for support programme that provide continuing education opportunities to rural doctors; outreach and education to improve health literacy and increase the signs of and treatments for illness; and for the Office on Women’s Health should appoint a rural liaison to coordinate services and activities; as well as further research to identify women’s overall health status and their access to and use of health care services in rural areas (e.g. health screenings, primary care, prenatal care, family planning services, oral care, vision and eye health services and mental health). Examples of successful rural initiatives include the University of Arkansas for Medical Sciences (UAMS) Institute for Digital Health & Innovation (IDHI) High-Risk Pregnancy Program, Wisconsin Rural Women’s Initiative gathering circle, and Chuuk Women’s Council Healthy Lifestyles Program to tackle diabetes.

While gender equality and health outcomes have been measured at a country level (with country-to-country comparisons made), there are few examples of within-country comparisons or specific rural analysis. 

Where next? For me, all of this highlights the importance of ensuring rurality is considered as part of the implementation of  the 10-year Women’s Health Strategy for England [at a national level] and by local health systems in their own plans and strategies (e.g. through the work of Integrated Care Systems, Primary Care Networks). If the health system belongs to us all, and must serve us all, will this renewed focus on women-specific issues lead to the transformational change the Government wants to see? Watch this space.  

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Jessica is a researcher/project manager at Rose Regeneration and a senior research fellow at The National Centre for Rural Health and Care (NCRHC). She is currently evaluating a support programme for patients waiting to receive NHS and local government services; and a Warm Hubs scheme. Jessica also sits on the board of a Housing Association that supports older people and a charity supporting Cambridgeshire’s rural communities. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk. 

Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ 

Blog: http://ruralwords.co.uk/ 

Twitter: @RoseRegen 

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