Periodic Reporting for period 3 - GENDHI (Gender and Health Inequalities : from embodiment to health care cascade)
Reporting period: 2023-07-01 to 2024-12-31
Summary of the context and overall objectives of the project
Inequalities in health represent a serious social injustice, and are an increasing concern for policymakers. The aim of the Gender and Health Inequalities (Gendhi) project is to understand health inequalities over the life course using a multi-disciplinary intersectional approach. We divide research into two main sections. The first, called “Gendered embodied health”, refers to the events, conditions and processes that shape health outcomes, the risk of exposure and the ability to identify a disease before being in contact with the healthcare system. The second, the “Gendered health care cascade”, refers to the nature and type of symptoms and requests expressed by patients, the way these are interpreted and treated by health professionals, how patients interact with the health system, and their trajectory therein. Gendhi focuses on four health conditions: cardiovascular pathologies, depression, colorectal cancer, and Covid-19.
Our secondary objectives are to:
1. Analyse processes of socialisation in childhood, adolescence, and young adulthood that result in different embodied dispositions contributing to health inequalities in the short and long term. We focus specifically on the way class and gender and race/ethnicity interact, producing these different dispositions within individuals.
2. Analyse how exposure to major protective or risk factors (such as professional exposures, diet, alcohol, tobacco, physical activity,) that relate to the four studied pathologies is gendered and how gender differences intersect with social class and race/ethnicity from childhood to adulthood.
3. Analyse how men and women from different social backgrounds recognise a given health problem and express their symptoms.
4. Analyse the gendered characteristics of current medical guidelines.
5. Analyse pathways to the health system, including access to screening tests.
6. Analyse how doctor-patient interactions are gendered and their effect on medical diagnosis, decisions, and prescriptions, and on patient’s ‘compliance’ and subsequent health trajectories.
Our secondary objectives are to:
1. Analyse processes of socialisation in childhood, adolescence, and young adulthood that result in different embodied dispositions contributing to health inequalities in the short and long term. We focus specifically on the way class and gender and race/ethnicity interact, producing these different dispositions within individuals.
2. Analyse how exposure to major protective or risk factors (such as professional exposures, diet, alcohol, tobacco, physical activity,) that relate to the four studied pathologies is gendered and how gender differences intersect with social class and race/ethnicity from childhood to adulthood.
3. Analyse how men and women from different social backgrounds recognise a given health problem and express their symptoms.
4. Analyse the gendered characteristics of current medical guidelines.
5. Analyse pathways to the health system, including access to screening tests.
6. Analyse how doctor-patient interactions are gendered and their effect on medical diagnosis, decisions, and prescriptions, and on patient’s ‘compliance’ and subsequent health trajectories.
Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far
We proposed a novel theoretical and methodological framework on the contribution of embodiment to health inequalities over the life course and its potential uses in epidemiology, integrating Krieger’s eco-social model of embodiment with an intersectional approach (Kelly-Irving & Delpierre, 2021; Soulier et al., 2021). Regarding the intertwined relations between the social and the biological, the adaptation and English translation of Darmon's book, Socialization, published by Polity Press in 2024 is crucial in our efforts to bring together the sociological concept of socialization and the epidemiological concept of embodiment. This book makes the concept of socialization, which is important in the Gendhi project, accessible to a wider international audience.
The Gendhi project provides a great opportunity to theorize and study embodied health. We are investigating gendered embodied health in childhood. On the qualitative side, we are conducting family monographs observing representations and practices of health in everyday family life. On the quantitative side, we are using data from the Étude Longitudinale Française depuis l'Enfance (ELFE) to examine how differential child socialization may affect child development outcomes.
In the Gendhi project we focus on three social dimensions (gender, race and class) and their intersections.
In her doctoral thesis, Colineaux (2023) examines the use of sex and gender in epidemiology, combining theory with quantitative methods and argues that in epidemiology, gender-related mechanisms should be taken into account in addition to sex differences. Three recent papers enabled us to make progress in conceptualising or measuring these social dimensions. They highlight the impact of gender on colorectal cancer (Martinez et al., 2024), of socioeconomic position across the lifecourse on biological health (Whitley et al., 2024), and of race inequalities in exposure to Covid19 (Warszawski et al., 2022).
Analyses using survey data from the Épidémiologie et conditions de vie (EpiCov) French cohort confirmed an unequal exposure to health risk factors. During the early phase of Covid-19, racialized minorities, male manual workers, and female caregivers in France were more likely to live in densely populated areas, overcrowding housing, work outside the home, and use public transportation; risk factors that rendered these groups more vulnerable to Covid-19 (Bajos, Counil, et al., 2021; Gosselin et al., 2022). Analyses using EpiCov also indicated that individuals at the bottom of the social hierarchy, racialised minorities, and those who distrust the government were more reluctant to get vaccinated against Sars-Cov-2 (Bajos, Counil, et al., 2021; Bajos et al., 2022a,b).
Ethnographic work on neuro-cardiovascular disease indicated that gender and class-based predispositions relate to individuals’ cultural capital and attitudes towards health practices (Darmon, 2021). This work also revealed that recovery from a pathology can be class-based; patients from lower socioeconomic groups are more vulnerable to functional impairments than those from higher socioeconomic groups (Darmon, 2021). Moreover, the loss and recovery of physical abilities vary by gender and social class (Darmon, 2022).
This work on neuro-cardiovascular disease also suggested that men and women perceive a given health problem and express their symptoms differently. Alcalde et al (2024) confirmed this hypothesis for depressive symptoms. Using network analysis, the study found similar symptom patterns but different network structures in men and women, suggesting gender-specific mechanisms in the activation of symptoms and depressive states.
Using mixed methods, we are examining the unequal pathways to the health system. For example, Spire et al. (2023) analysed the social determinants associated with the transition from attitudes towards vaccination to actual vaccination practices. People who had a recent migration background and on lower incomes were less likely to get vaccinated regardless of their initial intentions, suggesting that failure to target these specific groups reinforces existing social inequalities in COVID-19 vaccine uptake. Silberzan and al. (2024) examined hypertension control beyond the cascade of care framework and highlighted that applying a typical sequential approach may lead to the exclusion of some groups of participants who do not fit into the defined categories.
Our collective and multidisciplinary research project has implemented several initiatives to foster synergy and collaboration. We conducted regular coordination meetings with the PIs, we organised workshops, seminars, working groups and a two-day retreat to discuss the progress of the project.
A major achievement of the Gendhi project is the dissemination of our findings to the public health community. We regularly presented our work to medical audiences and emphasized the social production of health inequalities.
The Gendhi project provides a great opportunity to theorize and study embodied health. We are investigating gendered embodied health in childhood. On the qualitative side, we are conducting family monographs observing representations and practices of health in everyday family life. On the quantitative side, we are using data from the Étude Longitudinale Française depuis l'Enfance (ELFE) to examine how differential child socialization may affect child development outcomes.
In the Gendhi project we focus on three social dimensions (gender, race and class) and their intersections.
In her doctoral thesis, Colineaux (2023) examines the use of sex and gender in epidemiology, combining theory with quantitative methods and argues that in epidemiology, gender-related mechanisms should be taken into account in addition to sex differences. Three recent papers enabled us to make progress in conceptualising or measuring these social dimensions. They highlight the impact of gender on colorectal cancer (Martinez et al., 2024), of socioeconomic position across the lifecourse on biological health (Whitley et al., 2024), and of race inequalities in exposure to Covid19 (Warszawski et al., 2022).
Analyses using survey data from the Épidémiologie et conditions de vie (EpiCov) French cohort confirmed an unequal exposure to health risk factors. During the early phase of Covid-19, racialized minorities, male manual workers, and female caregivers in France were more likely to live in densely populated areas, overcrowding housing, work outside the home, and use public transportation; risk factors that rendered these groups more vulnerable to Covid-19 (Bajos, Counil, et al., 2021; Gosselin et al., 2022). Analyses using EpiCov also indicated that individuals at the bottom of the social hierarchy, racialised minorities, and those who distrust the government were more reluctant to get vaccinated against Sars-Cov-2 (Bajos, Counil, et al., 2021; Bajos et al., 2022a,b).
Ethnographic work on neuro-cardiovascular disease indicated that gender and class-based predispositions relate to individuals’ cultural capital and attitudes towards health practices (Darmon, 2021). This work also revealed that recovery from a pathology can be class-based; patients from lower socioeconomic groups are more vulnerable to functional impairments than those from higher socioeconomic groups (Darmon, 2021). Moreover, the loss and recovery of physical abilities vary by gender and social class (Darmon, 2022).
This work on neuro-cardiovascular disease also suggested that men and women perceive a given health problem and express their symptoms differently. Alcalde et al (2024) confirmed this hypothesis for depressive symptoms. Using network analysis, the study found similar symptom patterns but different network structures in men and women, suggesting gender-specific mechanisms in the activation of symptoms and depressive states.
Using mixed methods, we are examining the unequal pathways to the health system. For example, Spire et al. (2023) analysed the social determinants associated with the transition from attitudes towards vaccination to actual vaccination practices. People who had a recent migration background and on lower incomes were less likely to get vaccinated regardless of their initial intentions, suggesting that failure to target these specific groups reinforces existing social inequalities in COVID-19 vaccine uptake. Silberzan and al. (2024) examined hypertension control beyond the cascade of care framework and highlighted that applying a typical sequential approach may lead to the exclusion of some groups of participants who do not fit into the defined categories.
Our collective and multidisciplinary research project has implemented several initiatives to foster synergy and collaboration. We conducted regular coordination meetings with the PIs, we organised workshops, seminars, working groups and a two-day retreat to discuss the progress of the project.
A major achievement of the Gendhi project is the dissemination of our findings to the public health community. We regularly presented our work to medical audiences and emphasized the social production of health inequalities.
Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
The Gendhi project not only addresses important questions to disentangle the different ways in which social factors affect health inequality, but it does so from a novel multi-methods and multi-disciplinary perspective. Gendhi’s researchers come from different disciplines, sociology, demography, economy, epidemiology, etc., addressing different relevant research questions, proposing a variety of fields for data collection and analyses, and engaging in rich discussions about terminology, theory, and methodology. This unique set of conditions makes of Gendhi an enriching research environment that fosters the ambition to produce findings reaching beyond the sum of results of individual disciplines.
Our multi-disciplinary discussions have resulted in novel cross-discipline approaches to investigate structural inequalities. A noteworthy breakthrough is our progression from having conceived the Gendhi lifelong cascade model to its empirical operationalisation through different methodological approaches, and our findings regarding the Gendhi pathologies. The most innovative aspect of the project is the comprehensive nature of the Gendhi lifelong cascade model, starting with socialization in childhood and continuing through care of sick people until death. In order to validate the Gendhi lifelong cascade model, we intend to build causally-relevant evidence by triangulating qualitative and quantitative findings insofar as sociological and epidemiological approaches can reveal and explain social mechanisms and processes. Furthermore, our work provides concrete evidence of the importance of taking a gender-driven intersectional approach to the health cascade over the life course.
One of these approaches revisits the study of the process of socialisation. Gendhi is integrating insights from sociology and epidemiology to understand how differential socialisation, by class and gender, results in different attitudes and predispositions towards health, and thus, different embodiment of risk factors. Another section of the project integrates insights from sociology, demography and economy to shed light on the factors that explain differences in mortality and healthy life between women and men among the elderly. Combining sociological, economic and epidemiological perspectives, we are studying the gendered nature of medical guidelines regarding the diagnosis and follow-up of patients with cardiovascular pathologies. Drawing from sociological, epidemiological and medical perspectives, we opened up the discussion about the conceptual and methodological challenges of the definitions of sex and gender in quantitative research (Colineaux et al., 2022).
The Gendhi project is also expected to contribute to a better understanding of intersectionality through theory that stems from, and is nurtured by, empirical work. Focusing on gender in the study of the body and health has the potential to advance our understanding of how intersectionality operates. In other words, how do intersecting categories of gender, class and race lead to social situations and exposures that produce health inequalities?
The emergence of Covid-19 also changed the initial scope of the project. We included Covid-19 as one of the pathologies studied in Gendhi. This addition improved the visibility of Gendhi among the general public, the research community, and policy makers. At the same time, our initial focus on Alzheimer's /dementia evolved towards a broader research question on the process of ageing and its production of health inequalities over the life course. We expect that Gendhi will shed light on the ways that health inequalities are produced and maintained from different perspectives, in a way that has not yet been done in social sciences research.
Our multi-disciplinary discussions have resulted in novel cross-discipline approaches to investigate structural inequalities. A noteworthy breakthrough is our progression from having conceived the Gendhi lifelong cascade model to its empirical operationalisation through different methodological approaches, and our findings regarding the Gendhi pathologies. The most innovative aspect of the project is the comprehensive nature of the Gendhi lifelong cascade model, starting with socialization in childhood and continuing through care of sick people until death. In order to validate the Gendhi lifelong cascade model, we intend to build causally-relevant evidence by triangulating qualitative and quantitative findings insofar as sociological and epidemiological approaches can reveal and explain social mechanisms and processes. Furthermore, our work provides concrete evidence of the importance of taking a gender-driven intersectional approach to the health cascade over the life course.
One of these approaches revisits the study of the process of socialisation. Gendhi is integrating insights from sociology and epidemiology to understand how differential socialisation, by class and gender, results in different attitudes and predispositions towards health, and thus, different embodiment of risk factors. Another section of the project integrates insights from sociology, demography and economy to shed light on the factors that explain differences in mortality and healthy life between women and men among the elderly. Combining sociological, economic and epidemiological perspectives, we are studying the gendered nature of medical guidelines regarding the diagnosis and follow-up of patients with cardiovascular pathologies. Drawing from sociological, epidemiological and medical perspectives, we opened up the discussion about the conceptual and methodological challenges of the definitions of sex and gender in quantitative research (Colineaux et al., 2022).
The Gendhi project is also expected to contribute to a better understanding of intersectionality through theory that stems from, and is nurtured by, empirical work. Focusing on gender in the study of the body and health has the potential to advance our understanding of how intersectionality operates. In other words, how do intersecting categories of gender, class and race lead to social situations and exposures that produce health inequalities?
The emergence of Covid-19 also changed the initial scope of the project. We included Covid-19 as one of the pathologies studied in Gendhi. This addition improved the visibility of Gendhi among the general public, the research community, and policy makers. At the same time, our initial focus on Alzheimer's /dementia evolved towards a broader research question on the process of ageing and its production of health inequalities over the life course. We expect that Gendhi will shed light on the ways that health inequalities are produced and maintained from different perspectives, in a way that has not yet been done in social sciences research.