Gendered health inequalities in mental well-being? The Nordic countries in a comparative
perspective
Author(s): SIGRUN OLAFSDOTTIR
Source: Scandinavian Journal of Public Health , March 2017, Vol. 45, No. 2 (March 2017),
pp. 185-194
Published by: Sage Publications, Inc.
Stable URL: https://www.jstor.org/stable/10.2307/48615028
REFERENCES
Linked references are available on JSTOR for this article:
https://www.jstor.org/stable/10.2307/48615028?seq=1&cid=pdf-
reference#references_tab_contents
You may need to log in to JSTOR to access the linked references.
JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide
range of content in a trusted digital archive. We use information technology and tools to increase productivity and
facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
https://about.jstor.org/terms
Sage Publications, Inc. is collaborating with JSTOR to digitize, preserve and extend access to
Scandinavian Journal of Public Health
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
Scandinavian Journal of Public Health, 2017; 45: 185–194
https://doi.org/10.1177/1403494816686027
© Author(s) 2017
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1403494816686027
journals.sagepub.com/home/sjp
Decades of research on health and inequality show a
consistent pattern: those who are more vulnerable in
society have poorer health outcomes than those who
enjoy more advantages [1].The most consistent relationship
has perhaps been found for the impact of
education and income, whereas work on gender and
immigration has yielded more mixed findings [2].
The gender paradox in health is well known: women
live longer than men, but have more chronic and
mental health problems throughout the life course
[3]. Although biology plays some part in explaining
these differences, social factors also have a key role.
Researchers have pointed out that men generally
engage in a riskier lifestyle and work in more dangerous
occupations, whereas women’s health suffers
from inequality in paid and unpaid work [4].
The unequal status of men and women is a nearly
universal pattern across time and place, yet what is
viewed as appropriate for men and women in society
as well as the effort societies put into correcting those
inequalities varies drastically. The classification of
societies into welfare regimes has a long tradition
that began with the categorization of liberal, conservative
and social democratic societies by EspingAndersen
[5]. Countries such as the USA, the UK
and Australia fall into the category of liberal welfare
states; Germany, France and Italy represent conservative
states; and Norway, Sweden and Denmark are
examples of social democratic welfare states. EspingAndersen’s
focus was on how much societies do to
make individuals capable of surviving outside the
market, with a focus on various policies designed to
relieve individuals of insecurities created by the market.
Although hugely influential, his work was rapidly
criticized by feminist scholars for its lack of attention
to gender [6,7].This has led to a reformulation of his
original classification where more attention is paid to
gender [8]. For example, Korpi and colleagues [9,10]
divided countries into the dual-earner family model,
the market-oriented model and the traditional family
Gendered health inequalities in mental well-being? The Nordic
countries in a comparative perspective
SIGRUN OLAFSDOTTIR
University of Iceland, Iceland
Abstract
Aims: The aims of this study were to: (a) compare gender differences in mental well-being in the Nordic countries with gender
differences in 28 other countries around the world; and (b) evaluate whether gender differences in the Nordic countries
remain when other social and lifestyle factors are taken into account. Methods: Data were obtained from 32 countries around
the world that participated in the 2011 health module of the International Social Survey Programme. Ordered logit regression
models were used to evaluate whether gender differences remained significant when other social and lifestyle factors were
considered. Results: Gender differences in mental well-being in the Nordic countries are not particularly small and the four
countries do not cluster together.The gender differences remain when other social and lifestyle factors are taken into account.
Conclusions: There appears to be a similar Nordic health paradox for mental well-being outcomes as for physical
health outcomes. Although there may be multiple reasons for this, continued gender equality, including sex
segregation in the labour market and gendered expectations, are considered to play a part.
Key Words: Mental well-being, gender inequality, Nordic health paradox
Correspondence: Sigrun Olafsdottir, University of Iceland, Oddi, Sturlugötu 3, 101 Reykjavík, Iceland. E-mail: sigruno@hi.is
(Accepted XX MONTH XXXX)
686027SJP0010.1177/1403494816686027S. OlafsdottirGendered mental health inequalities
research-article2016
Original Article
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
186    S. Olafsdottir
policy model. In Esping-Andersen’s typology,
these roughly match the social democratic, liberal
and conservative models, respectively. With respect
to gender, the dual-earner family model countries
encourage women’s participation in the labour force
and promote policies that allow men and women to
combine parenthood and paid work; the market-oriented
model countries do not discourage women
from participation in the labour force, but leave it to
the market to control how gender relations play out,
with an emphasis on private, market-based solutions
to care work; and the traditional family policy model
countries have historically allocated care work to the
family, providing little support for women participating
in the labour force.
Although the regime approach has enjoyed great
popularity among scholars engaged in cross-national
work, there has been an increased reliance on specific
policies and indicators, which are better able to trace
the specific mechanisms that affect inequality. Along
those lines, Pascall and Lewis [11] have identified
five policy areas that promote gender equality. They
are: (a) policies to promote political representation
(e.g. proportional representation and gender quotas);
(b) polices to promote gender-equitable use of time
(e.g. equal value for part-time work and school
scheduling); (c) family policies (e.g. parental leave
and child and elder care policies); (d) policies to promote
equal income (e.g. equal opportunity in earnings
and division of pension rights on divorce); and
(e) employment policies (e.g. labour market regulations
to increase equality and equal pay). Although it
is important to consider different and potentially
contradictory ways in which societies can promote
gender equality, one fact consistently remains: the
Nordic countries clearly do the most to create and
maintain equality between men and women. This
effort should have health implications, exemplified in
the theory of the fundamental causes of disease,
where it is clear that as long as we have societal inequality,
we will have health inequality [12,13].
Consequently, if a society attempts and succeeds in
reducing some type of inequality, there should be less
health inequalities of that type in that society. Yet
research on the health advantages of the Nordic
countries has yielded mixed findings.
Perhaps the most perplexing finding from studies
in the Nordic context is that although theoretical
expectations would lead us to think that citizens in
these countries should enjoy better health and less
health inequality than those elsewhere in the world,
this has not proved to be the case. In fact, this finding
has been consistent enough to be referred to as the
health paradox of the welfare state [14]. This paradox,
emerging from a pattern first found in the 1980s,
indicated that health inequalities were not smaller in
larger welfare states in general and the Nordic countries
in particular [15] and this finding has been confirmed
for the 1990s [16] and again in the 2000s
[17,18].
Focusing on gender, Bambra et al. [19] found evidence
that both supported and countered welfare
state theory. Examining self-rated health, they
showed that, as expected, women in the social democratic
countries were less likely to report poor health
than women in the southern regime (Portugal, Spain
and Italy), yet they were more likely to do so than
women in conservative countries. Using a measure
that captures the total inequality in life expectancy,
researchers have shown that the Nordic countries
have the highest life expectancies and lowest inequalities
for men in 37 countries, but the same was not
true for women [20]. Moving to the less studied outcome
of mental health, research has shown that the
family-friendly work policies of Finland [21] may
result in better mental health for women and that
women living in US states with better reproductive
rights have lower levels of depression [22].
Despite the sociological focus on the relationship
between individuals and society, sociologists have
only relatively recently started to theoretically and
empirically test the impact of macro-level institutional
arrangements on health and health inequalities
[23,24]. The last decade has witnessed a surge in
cross-national health research, albeit more frequently
focused on class-based than gender-based inequalities
[25,26]. In a review of work that has examined
the upstream determinants of health inequalities
between men and women, Borrell et al. [27] identified
19 papers that empirically examined the impact
of gender equality policies, gender or welfare state
regimes, or compared policies across countries, states
or macro-administrative units.The most likely health
outcome to be examined in those papers was selfrated
health, with only three of them focusing on
mental health outcomes. It is important to consider a
variety of health measures to gain a fuller understanding
of health and health inequalities across
countries. I therefore used three measures of mental
well-being in this research, which aligns well with
how theWorld Health Organization (WHO) suggests
we should think about health around the world. More
specifically, the WHO defines health as: ‘a state of
complete physical, mental and social well-being and
not merely the absence of disease or infirmity’ [28].
I used data from the 2011 International Social
Service Programme (ISSP) Health module to explore
two interrelated research questions: (a) how large is
the gender difference in mental well-being in the
Nordic countries (Denmark, Finland, Norway and
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
Gendered mental health inequalities   187
Sweden) compared with 28 other countries across
the globe; and (b) if gender differences are observed
in the Nordic countries, do they remain even when
other social demographic and lifestyle factors are
introduced?These questions are important, as theory
would expect smaller gender differences in the
Nordic countries, yet numerous studies have determined
the Nordic health paradox, especially in terms
of physical health outcomes [14–18,20]. In this study,
I relied on relatively new data from the ISSP and join
the few comparative studies that focus on mental
health outcomes, rather than the much more frequently
used physical health outcomes.
Data and methods
The data were taken from the 2011 ISSP. The ISSP
is a collaboration of survey researchers in more than
40 countries with an emphasis on theoretical, methodological
and conceptual coordination. Each survey
module is designed collaboratively and a standard
English questionnaire is agreed upon by representatives
from each country. The questionnaire is then
translated into different languages and adapted to
the national culture and context. The ISSP guidelines
require a nationally representative sample, but
the countries have different fielding plans that are
adjusted to each context. Each country fielding plan
must be approved by the ISSP methodological committee
prior to joining the ISSP and no deviation is
allowed unless they are specifically approved by the
committee.The ISSP has rotating modules that focus
on issues of key concern to social scientists. In 2011,
the focus was on health and included questions on
health care reform, attitudes towards medical doctors,
health behaviour and health outcomes.
The health module was fielded in 32 countries
and although the focus of this paper is on the Nordic
countries, they are all used as comparison cases for
gender differences. Specifically, the participating
Nordic countries were: Denmark (N=1388), Finland
(N=1340), Norway (N=1834) and Sweden
(N=1158). The non-Nordic comparison countries
were: Australia (N=1946), Belgium (N=3083),
Bulgaria (N=1003), Chile (N=1559), China
(N=5620), Croatia (N=1210), Czech Republic
(N=1210), France (N=3319), Germany (N=1681),
Israel (N=1220), Italy (N=1186), Japan (N=1306),
Lithuania (N=1187), the Netherlands (N=1472),
Philippines (N=1200), Poland (N=1115), Portugal
(N=1022), Russia (N=1511), Slovak Republic
(N=1128), Slovenia (N=1082), South Africa
(N=3004),South Korea (N=1535),Spain (N=2712),
Switzerland (N=1212), Taiwan (N=2199), Turkey
(N=1559), UK (N=936) and USA (N=1550).
Dependent variables
The mental well-being of the respondents was captured
by three questions asking:‘During the past four
weeks how often (1) have you felt unhappy and
depressed, (2) have you lost confidence in yourself
and (3) have you felt you could not overcome your
problems?’ The five response categories were: (1)
never; (2) seldom; (3) sometimes; (4) often; and (5)
very often.
Independent variables
Gender was the key variable of interest in this paper
and was measured by a dummy variable (1=female;
0=male).To evaluate the impact of gender on mental
well-being in the Nordic countries, the analysis controlled
for additional social demographics and lifestyle.The
other social demographics were: (1) marital
status (married or cohabitating=1; not married=0);
(2) age; (3) education (1=college educated; 0=noncollege
educated); (4) labour force status (1=in the
labour force; 0=not in the labour force); and (5)
health status (1=long-standing or chronic illness or
disability; 0=no such condition). The measures for
lifestyle were: (1) smoking behaviour (1=smokes at
least one cigarette a day; 0=never smoked or has quit
smoking); (2) alcohol consumption; (3) physical
activity; and (4) fruit or vegetable consumption.The
exact wording for the three last variables was: ‘How
often do you: (1) drink four or more alcoholic drinks
on the same day; (2) do physical activity for at least
20 minutes that makes you sweat or breathe more
heavily than usual; and (3) eat fresh fruit or vegetables’.
The response categories were: (1) never; (2)
once a month or less often; (3) several times a month;
(4) several times a week; and (5) daily.
Analysis
The analysis proceeded in two steps. The first step
was to evaluate the gender differences in mental wellbeing
in the Nordic countries compared with other
ISSP countries. The difference was calculated by
subtracting the country mean for women from the
country mean for men. If the number was positive,
the men had reported better mental well-being than
the women and vice versa if it was negative. This
analysis also tested whether the gender differences
were significant or not.The second step was to take a
closer look at gender differences in mental well-being
in the Nordic countries by conducting a series of
country-specific ordered logit regressions, where
other variables associated with mental well-being
were introduced to evaluate whether the gender
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
188    S. Olafsdottir
differences remained. Ordered logit regressions as
used here are the most appropriate method for
ordered variables; however, a problem associated
with such models is that the assumption of parallel
lines/proportional odds does not hold [29]. This
assumption was broken (but only barely so) in only
two (depression in Finland and depression in
Sweden) of the 12 regression models. Consequently,
and with caution regarding those two models, the
analysis relies on ordered logit regression models.
Results
Mental well-being in the Nordic countries in a
comparative perspective
The first step of the analysis was to evaluate whether
there were significant gender differences in mental
well-being in the Nordic countries, as well as how
these countries compared with other ISSP countries.
The high levels of gender equality in the
Nordic countries should, at least in theory, result in
fewer gender differences than expected in less equal
countries, yet current research has found mixed
evidence for how the extensive social policies in the
Nordic countries impact health and health inequalities.
Figures 1–3 explore the size of the gender differences
in the 32 countries. A patterned bar
indicates a significant gender difference in a Nordic
country, a black bar indicates a significant gender
difference in a non-Nordic country and a grey bar
indicates a non-significant gender difference in any
country.
Figure 1 shows the gender differences for reporting
feeling unhappy or depressed.The figure shows
relatively large cross-national variation and that
women are significantly more likely to report such
feelings in all but three countries (Japan, Australia
and the Philippines). The gender differences were
largest in Portugal, Chile and Bulgaria. Although
there was some indication that countries with
higher levels of inequality were towards the top and
some countries with lower levels were closer to the
Figure 1.  Gender differences in the Nordic countries in a comparative perspective: Reporting feeling unhappy or depressed.
Patterned bars indicate significant gender differences in the Nordic countries; black bars indicate significant gender differences outside the
Nordic countries; grey bars indicate non-significant gender differences in all countries.
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
Gendered mental health inequalities   189
bottom, the pattern was far from clear. Even more
importantly, the Nordic countries neither had particularly
small gender differences, nor did they
cluster together with similar levels of difference.
Specifically, Norway had the tenth largest gender
differences (0.3), followed by Sweden (0.22), then
Denmark (0.18) and finally Finland, which was the
country with the fourth smallest gender differences
(0.12).
Figure 2 examines the gender differences in
reporting to have lost confidence in oneself. A similar
picture emerges to Figure 1.Women were more likely
to report a lack of confidence in themselves than men
and the gender differences were significant in all
countries except for five.The gender differences were
largest in Portugal, Bulgaria and France, all countries
that also had high gender differences for feeling
unhappy or depressed. Within the Nordic countries,
the pattern from Figure 1 re-emerged; the difference
was greatest in Norway, then Sweden, Denmark and
finally Finland. However, although the gender differences
were small but significant in Finland previously,
they were not for this measure.
Figure 3 shows the gender differences for feeling
that one could not overcome one’s problems. Once
again, a similar picture emerges with relatively large
cross-national differences and no clear patterning of
nations according to levels of gender inequality.
Figure 2.  Gender differences in the Nordic countries in a comparative perspective: Reporting having lost confidence in oneself.
Patterned bars indicate significant gender differences in the Nordic countries; black bars indicate significant gender differences outside the
Nordic countries; grey bars indicate non-significant gender differences in all countries.
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
190    S. Olafsdottir
Overall, women were more likely to report that they
have been unable to overcome their problems. The
gender difference was not significant in only four
countries: Switzerland, Finland, Australia and the
Slovak Republic. Again, we saw the largest gender
differences in Bulgaria, France and Portugal.
Focusing on the Nordic countries, the largest gender
difference was again in Norway, followed by
Denmark, then Sweden, with non-significant gender
differences in Finland. As a whole, this comparison
showed that the Nordic countries neither clustered
together, nor did they have particularly low levels of
gender difference in all cases, something that might
be expected from the high levels of gender equality in
those countries.
A closer look at the Nordic countries: gender,
social demographics and lifestyle
The cross-national comparison between the four
Nordic countries and 28 other countries around the
world established significant gender differences for
all of the measures for mental well-being in most of
the Nordic countries. A second step of the analysis
was to evaluate what happens to those gender differences
when other factors are introduced, specifically
other social demographic variables and lifestyle factors.
The overall results showed that the gender differences
remained (or appeared) when those other
factors were considered simultaneously. Table I
turns to more specific findings for the likelihood of
Figure 3.  Gender differences in the Nordic countries in a comparative perspective: Reporting unable to overcome one’s problems
Patterned bars indicate significant gender differences in the Nordic countries; black bars indicate significant gender differences outside the
Nordic countries; grey bars indicate non-significant gender differences in all countries.
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
Gendered mental health inequalities   191
reporting feeling depressed or unhappy in the four
Nordic countries.
Table I shows that women were significantly more
likely than men to report having felt unhappy or
depressed in the past four weeks in all the Nordic
countries. In fact, it was one of only three factors that
was significantly associated with depression in all
four countries. The other factors that always mattered
for depression were having a long-standing illness
and not consuming fruits and vegetables
regularly. Not surprisingly, those who reported a
long-standing chronic illness or disability report
higher levels of unhappiness and depression, in contrast
with those who consumed more fruits and vegetables.
Other relationships were as to be expected,
but not consistently significant.With respect to social
demographics, married people were less likely to
report unhappiness in Denmark, Norway and
Sweden, and the same was true for those with a college
education in Norway and those in the labour
force in Denmark, Finland and Norway.Turning our
attention to lifestyle, the analysis showed that those
who smoked were more likely to report depression in
Finland, Norway and Sweden, and those who exercised
more were less likely to do so in Denmark,
Finland and Sweden.
Table II shows the results of the ordered logit for
the likelihood of reporting loss of confidence in oneself.
Again, women in all four Nordic countries were
more likely to report loss of confidence then men,
those with long-lasting illness were more likely to do
so in all four countries, and those who consumed
fruits and vegetables regularly were less likely to do
so. Here, there was also a consistent pattern regarding
labour market status; specifically, those in the
labour force in all four Nordic countries were less
likely to have lost confidence in themselves. Other
patterns were less consistent. Married people were
less likely to report loss of confidence in Sweden, as
were older people in Denmark, Finland and Norway
and those with a college degree in Denmark. For lifestyle
variables, those who drank more were more
likely to report loss of confidence in Finland and
those who exercised were less likely to do so in
Finland and Sweden.
Table III presents the results from the ordered
logit regression on the likelihood of feeling unable to
overcome the problems one faces. As with the two
other measures of mental well-being, women in all
countries were more likely to report a lack of ability
to overcome problems than men. The same consistent
patterns appeared as for lack of confidence: those
in the labour force and those who consumed fruits
and vegetables more frequently were less likely to
report being unable to overcome their problems,
whereas those who had a long-standing illness were
more likely to do so. Looking at other variables, married
people were less likely to report that they could
not overcome problems, as were older people in
Norway. College educated people were also less likely
to report being unable to overcome problems in
Norway and Sweden. Looking at lifestyle factors,
Table I.  Ordered logit regression of reporting feeling depressed or unhappy in the Nordic countries (2011 ISSP).
Denmark Finland Norway Sweden
Female sex 0.432** 0.375** 0.618** 0.507**
Social demographics  
 Married –0.343** –0.164 –0.335** –0.427**
 Age –0.007 –0.002 –0.006 0.000
 College –0.201 0.109 –0.188* –0.094
  In the labour force –0.291* –0.447** –0.394** –0.129
  Long-standing illness 0.649** 0.568** 0.795** 0.867**
Lifestyle  
 Smoking 0.196 0.306* 0.305* 0.505**
  Alcohol consumption 0.049 0.105 –0.018 –0.007
  Physical activity –0.123** –0.152** –0.083 –0.143*
  Fruits and vegetables –0.206** –0.202** –0.308* –0.235*
Cut 1 –1.988 –1.761 –2.837 –2.801
Cut 2 –0.407 –0.231 –1.167 –0.969
Cut 3 1.019 1.318 0.597 0.956
Cut 4 2.187 2.794 1.735 2.051
Log-likelihood –1611.880 –1571.950 –2111.818 –1265.276
LR test 110.387 88.323 203.131 106.401
Pseudo R2 0.085 0.074 0.123 0.109
N 1314 1201 1630 967
*p<0.05; **p<0.01.
Pseudo R2 values are McKelvey and Zavonia’s R2 values.
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
192    S. Olafsdottir
those who smoked were more likely to report being
unable to overcome problems, but those who consumed
more alcohol were less likely to report this in
Sweden, as were those who exercised more in Finland
and Sweden. Taken together, the findings show that
gender was a persistent predictor of mental wellbeing
in all the Nordic countries and the pattern was
clear: women were less likely to report mental wellbeing
than their male counterparts.
Discussion
I examined the size of gender differences in mental
well-being in the Nordic countries compared with 28
Table II.  Ordered logit regression of reporting to have lost confidence in oneself in the Nordic countries (2011 ISSP).
Denmark Finland Norway Sweden
Female sex 0.590** 0.300* 0.615** 0.693**
Other social demographics  
 Married –0.095 –0.079 –0.122 –0.331*
 Age –0.017** –0.013** –0.011** –0.008
 College –0.344* –0.052 –0.034 –0.213
  In the labour force –0.390** –0.589** –0.486** –0.379**
  Long-standing illness 0.556** 0.446** 0.511** 0.747**
Lifestyle  
 Smoking 0.254 0.030 0.101 0.327
  Alcohol consumption 0.021 0.211** 0.081 0.034
  Physical activity –0.087 –0.164** –0.026 –0.190**
  Fruits and vegetables –0.259** –0.189** 0.241** –0.211*
Cut 1 –2.269 –1.668 –1.625 –2.062
Cut 2 –0.837 –0.217 –0.144 –0.578
Cut 3 0.575 1.418 1.425 0.980
Cut 4 1.488 2.389 2.867 2.018
Log-likelihood –1514.248 –1404.331 –1940.701 –1167.582
LR test 123.004 87.069 118.324 116.197
Pseudo R2 0.099 0.077 0.076 0.120
N 1310 1202 1620 963
*p<0.05; **p<0.01.
Pseudo R2 values are McKelvey and Zavonia’s R2 values.
Table III.  Ordered logit regression of reporting to be unable to overcome one’s problems in the Nordic countries (2011 ISSP).
Denmark Finland Norway Sweden
Female sex 0.439** 0.323** 0.419** 0.306**
Other social demographics  
 Married –0.181 0.024 –0.218* –0.170
 Age –0.004 –0.002 –0.009** –0.004
 College –0.299 –0.043 –0.279** –0.360**
  In the labour force –0.440** –0.555** –0.580** –0.399**
  Long-standing illness 0.598** 0.486** 0.835** 0.962**
Lifestyle  
 Smoking 0.238 0.136 0.152 0.618**
  Alcohol consumption 0.002 0.074 –0.097 –0.178*
  Physical activity –0.095 –0.146* –0.069 –0.173**
  Fruits and vegetables –0.206** –0.269** –0.336** –0.223**
Cut 1 –1.591 –1.494 –2.650 –2.145
Cut 2 –0.020 –0.154 –1.201 –0.759
Cut 3 1.304 1.345 0.231 0.656
Cut 4 2.290 2.450 1.380 1.569
Log-likelihood –1490.903 –1406.796 –1924.845 –1126.183
LR test 101.041 83.220 209.757 135.001
Pseudo R2 0.082 0.074 0.131 0.143
N 1311 1205 1617 956
*p<0.05; **p<0.01.
Pseudo R2 values are McKelvey and Zavonia’s R2 values.
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
Gendered mental health inequalities   193
other countries around the world and tested whether
the gender differences remained when several other
factors were taken into account.The results indicated
that high levels of gender equality may not be as successful
in eliminating inequalities in mental wellbeing
as theory would expect. Specifically, the gender
differences in mental well-being were neither particularly
small in all four Nordic countries, nor did the
countries cluster together as a coherent regime. In
addition, observed gender differences may be due to
differences in other types of status and lifestyle
between men and women, yet models controlling for
these do still show significant gender differences.
How do we explain these patterns?The most obvious
explanation may be that despite high levels of
gender equality in many areas of social life, perfect
equality between genders has still not been achieved.
For example, there are still inequalities in pay
between men and women and research has shown
that even though Nordic men do more housework
than their counterparts in other countries, their
female counterparts still do more [30,31]. However,
the most important factor, especially in explaining
how the Nordic countries compare with other countries,
may be at least two-fold. First, the way that the
labour market is organized maintains the traditional
division of labour between the genders. Scholars have
pointed out that the labour market in the Nordic
countries is highly sex-segregated, even more so than
in many other countries, including the liberal welfare
states [32]. Some have argued that social policy in
the Nordic countries, with its emphasis on female
labour force participation, has in reality simply
removed women from their traditional place within
the home to a similar place within the public sector
– that is, rather than taking care of children, the sick
and the elderly through unpaid work within the
home, they now do the same in the public sector,
rewarded with salaries that are generally lower than
those that men enjoy in the private sector or in more
highly paid positions in the public system.
Second, there may be a mismatch between expectations
and reality for women living in the Nordic
countries and this may be especially important for
mental well-being. From a young age, Nordic women
are taught that they are equal to men in every way,
that they can do the same jobs in the labour market
and deserve the same opportunities and rewards as
their male counterparts.Yet they are still likely to hit
the glass ceiling at some point, like their counterparts
in other countries, and they are still likely to have
partners who do less than them when it comes to
housework and the care of children and elderly relatives.
Consequently, although they may objectively
experience more equality than women in most other
societies, this may be accompanied by even greater
expectations of a perfectly equal world. Along those
lines, Sachweh and Olafsdottir [33] compared the
perceptions of reality regarding stratification and
aspirations of stratification in Sweden and Germany.
They found that although the Swedes correctly identified
their society as more equal than their counterparts
in the USA and Germany, they had even greater
aspirations than the citizens in those countries and
were more likely to want even greater equality in their
society. This mismatch is likely to have health implications
for both men and women and those may be
even more consequential for mental health than for
physical health as they go to the core of how we experience
ourselves and our role in society.
This study is not without limitations. First, I
relied on self-reported items of mental well-being
embedded in cultural experiences and expressions.
Nevertheless, research has generally shown that selfrated
health is a good measure to compare health
across societies and my inclusion of three measures
that capture mental well-being constitutes a strength.
Moreover, in the comparison I relied on the gender
differences rather than arguing that the mental wellbeing
of women is better in one country than in
another. Second, although the theoretical motivation
for the paper is the underlying assumption that gender
differences should be smaller in the Nordic countries,
the paper does not explicitly test the impact of
welfare state arrangements and policies. Rather, this
paper is a first step in considering and empirically
testing what impacts the mental health of men and
women in the Nordic countries and how they compare
with their counterparts in other societies. It is
important for future work to build on existing theories
and provide more nuanced empirical evidence
for how the societal and individual factors come
together to create gender-based health inequalities.
To conclude, this paper constitutes an early step in
considering how the Nordic welfare state may relate
to the mental health of men and women. It highlights
two important research trajectories, one of continued
work that compares a large number of countries and
one of more detailed work that looks at within-country
differences. It also underscores the importance of
paying attention to multiple sources of inequalities
within and across societies. Much of the crossnational
work undertaken on inequality and health
focuses on class-based inequalities, yet we know that
there are multiple other important axes of inequalities
that exist, including those based on gender, race/
ethnicity, immigration, religion and sexual orientation.
Moving beyond this paper, what is even more
important is to develop research agendas that explore
the intersections of inequalities, and to consolidate
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms
194    S. Olafsdottir
our knowledge about class and health versus gender
and health versus race and health. Only then will we
start to get a complete picture of how and why inequality
has such a profound impact, not only on
whether we live or die, but even more importantly on
the quality of our lives throughout our life courses.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The author(s) received no financial support for
the research, authorship, and/or publication of this
article.
References
	 [1]	 Phelan J and Link B. Fundamental cause theory. In: CockerhamWC
(ed.) Medical sociology on the move: New directions
in theory. NewYork: Springer, 2013, pp.105–25.
	 [2]	 Beckfield J, Olafsdottir S and Bakhtiari E. Health inequalities
in global context. Am Behav Scientist 2013;57:1014–39.
	 [3]	 Verbrugge LM. Gender and health: An update on hypotheses
and evidence. J Health Soc Behav 1985;26:156–82.
	 [4]	 Ross CE and Bird CE. Sex stratification and health lifestyle:
Consequences for men’s and women’s perceived health. J
Health Soc Behav 1994;35:161–78.
	[5]	 Esping-Andersen G. The three worlds of welfare capitalism.
Princeton, NJ: Princeton University Press, 1990.
	 [6]	 O’Connor JS. Gender, class and citizenship in the comparative
analysis of welfare state regimes:Theoretical and methodological
issues. Br J Sociol 1993;44:501–18.
	 [7]	 Orloff AS. Gender and the social rights of citizenship: The
comparative analysis of gender relations and welfare states.
Am Sociol Rev 1993;58:303–28.
	[8]	 Esping-Andersen G. Why we need a new welfare state.
Oxford: Oxford University Press, 2002.
	[9]	 Korpi W. Faces of inequality: gender, class, and patterns
of inequalities in different types of welfare states. Soc Pol
2000;7:127–91.
	[10]	 Korpi W, Ferrarini T and Englund S. Women’s opportunities
under different constellations of family policies in western countries:
A comparative analysis. Luxembourg Income Study
Working Paper Series No. 556. Luxembourg: Luxembourg
Income Study, 2010.
	[11]	 Pascall G and Lewis J. Emerging gender regimes and policies
for gender equality in a wider Europe. J Soc Policy
2004;33:373–94.
	[12]	 Link BG and Phelan J. Social conditions as fundamental
causes of disease. J Health Soc Behav 1995;35:80–94.
	[13]	 Phelan JC, Link BG and Tehranifar P. Social conditions
as fundamental causes of health inequalities: Theory,
evidence, and policy implications. J Health Soc Behav
2010;51:S28-40.
	[14]	 Mackenbach JP. The persistence of health inequalities in
modern welfare states:The explanation of a paradox. Soc Sci
Med 2012;75:761–9.
	[15]	 Mackenbach JP, Kunst AE, Cavelaars AEJM, et al. Socioeconomic
inequalities in morbidity and mortality in western
Europe. Lancet 1997;349:1655–9.
	[16]	 Mackenbach JP, Stirbu I, Roskam A-JR, et  al. Socioeconomic
inequalities in health in 22 European countries. N
Engl J Med 2008;358:2468–81.
	[17]	 Eikemo TA, Bambra C, Joyce K, et al.Welfare state regimes
and income-related health inequalities: A comparison of 23
European countries. Eur J Public Health 2008;18:593–9.
	[18]	 Eikemo TA, Huisman M, Bambra C, et al. Health inequalities
according to educational level in different welfare
regimes:A comparison of 23 European countries. Soc Health
Illness 2008;30:565–82.
	[19]	 Bambra C, Pope D, SwamiV, et al. Gender, health inequalities
and welfare state regimes: A cross-national study of
13 European countries. J Epidemiol Community Health
2009;63:38–44.
	[20]	 Popham F, Dibben C and Bambra C. Are health inequalities
really not the smallest in the Nordic welfare states? A comparison
of mortality inequality in 37 countries. J Epidemiol
Community Health 2013;67:412–8.
	[21]	 Chandola T, Martikainen P, Bartley M, et al. Does conflict
between home and work explain the effect of multiple roles
on mental health? A comparative study of Finland, Japan,
and the UK. Int J Epidemiol 2004;33:884–93.
	[22]	Chen Y-Y, Subramanian SV, Acevedo-Garcia D, et  al.
Women’s status and depressive symptoms: A multilevel
analysis. Soc Sci Med 2005;60:49–60.
	[23]	 Olafsdottir S and Beckfield J. Health and the social rights
of citizenship: Integrating welfare state theory and medical
sociology. In: Pescosolido BA, Martin JK, McLeod JD, et al.
(eds) Handbook of the sociology of health, illness, and healing:
A blueprint for the 21st century. New York: Springer, 2011,
pp.101–15.
	[24]	 Beckfield J, Bambra C, Eikemo TA, et al. An institutional
theory of welfare state effects on the distribution of population
health. Soc Theory Health 2015;13:227–44.
	[25]	Bambra C, Netuveli G and Eikemo TA. Welfare state
regime life courses: The development of Western European
welfare state regimes and age-related patterns of educational
inequalities in self-reported health. Int J Health Serv
2010;40:399–420.
	[26]	 Huijts T, Eikemo TA and Skalická V. Income-related health
inequalities in the Nordic countries: Examining the role
of education, occupational class, and age. Soc Sci Med
2010;71:1964–72.
	[27]	 Borrell C, Palència L, Muntaner C, et al. Influence of macrosocial
policies on women’s health and gender inequalities
in health. Epidemiol Rev 2014;36:31–48.
	[28]	 Preamble to the Constitution of the World Health Organization
as adopted by the International Health Conference, New York,
19–22 June 1946; signed on 22 July 1946 by the representatives
of 61 States and entered into force on 7 April 1948. Official
Records of the World Health Organization no. 2, p.100.
Geneva:WHO.
	[29]	 Long JS. Regression models for categorical and limited
dependent variables. Thousand Oaks, CA: SAGE Publications,
1997.
	[30]	 Gunnarsdottir H, Petzold M and Povlsen L. Time pressure
among parents in the Nordic countries: A populationbased
cross-sectional study. Scand J Public Health 2014;42:
137–45.
	[31]	 Treas J andTaiT. Gender inequality in housework across 20
European nations: Lessons from gender stratification theories.
Sex Roles 2016;74:495–511.
	[32]	 Charles M. Cross-national variation in occupational sex segregation.
Am Sociol Rev 1992;57:483–502.
	[33]	 Sachweh P and Olafsdottir S. The welfare state and equality?
Stratification realities and aspirations in three welfare
regimes. Eur Sociol Rev 2012;28:149–68.
This content downloaded from
147.251.180.140 on Tue, 14 Feb 2023 09:52:05 UTC
All use subject to https://about.jstor.org/terms