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Scandinavian Journal of Public Health
DOI: 10.1080/14034940701362194
2007; 35; 577Scand J Public Health
Marianne Upmark, Karin Borg and Kristina Alexanderson
absentees
Gender differences in experiencing negative encounters with healthcare: A study of long-term sickness
http://sjp.sagepub.com/cgi/content/abstract/35/6/577
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ORIGINAL ARTICLE
Gender differences in experiencing negative encounters with
healthcare: A study of long-term sickness absentees
MARIANNE UPMARK1,2
, KARIN BORG3
& KRISTINA ALEXANDERSON1
1
Section of Personal Injury Prevention, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, 2
Department
of Public Health Sciences, Karolinska Institutet, Stockholm, and 3
Division of Social Medicine and Public Health, Department
of Health and Society, Faculty of Health Sciences, Linko¨ping, Sweden
Abstract
Aim: In most countries there are gender differences in sickness absence and in absentees' return to work (RTW). According
to different theories sick-listed persons' experiences of encounters with healthcare professionals can influence self-esteem
and RTW. The aim was to analyse gender differences in sickness absentees' experiences of negative encounters with
healthcare professionals. Methods: A questionnaire, comprising numerous questions on experiences of positive and negative
encounters with professionals, was constructed and sent to 10,100 individuals who had been on sick leave for the last 6­8
months. The response rate was 58% (n55,802). Results: Almost one-third (32%) of the female respondents and one-quarter
of the male (24%), respectively, had experienced negative encounters. The most common of such experiences among both
women and men were: that they were treated with indifference, with disrespect, that the professional did not take his/her
time, did not listen, did not believe in, or doubted complaints. In regression analyses the women had higher significant
crude odds ratios, ranging from 1.29 to 1.71, for agreeing to the separate statements on negative encounters. When
adjusting for age, ethnicity, and level of education the gender differences were still significant for 14 of the 23 the
statements. Conclusion: Women's high rate of sickness absence is considered a problem in most countries. The subjective
experiences of women are an important factor to consider in efforts aiming at reducing the sick-leave rates. One important
endeavour among professionals in healthcare could be to shift the focus towards a more empowering professional role.
Key Words: Gender, negative encounter, sickness absence, sick leave
Background
In most countries there are gender differences in
sickness absence and in absentees' return to work
(RTW). According to different theories sick-listed
persons' experiences of encounters with healthcare
professionals can influence self-esteem and RTW
[1].
Medical encounters unfold according to a complex
interplay of style, perception, and adaptation in
an interpersonal context reflecting the interactanťs
goal, skills, perceptions, and emotions as well as the
constraints and opportunities created by the actions
of their partners. Gender differences may in these
encounters come from several sources including
differences in men's and women's communicative
styles and may occur within a number of contexts
[2]. These encounters are influenced by values and
power relations, as well as by the cultural context in
general. Thus, gender, as an accomplishment rather
than an individual difference and as one important
aspect of the division of power in a society, could be
expected to affect these encounters [3]. In the
patient­physician relationship patients are generally
considered to have less status and power (power
imbalance) than medical professionals.
Gender differences in communication in general
and in clinical encounters specifically have been
reviewed by Elderkin-Thompson & Waitzkin [4].
Physicians tend to give female patients more time,
Correspondence: Marianne Upmark, Personal Injury Prevention, Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden.
Tel: +46 8 524 832 00. Fax: +46 8 524 832 05. E-mail: marianne.upmark@sll.se
(Accepted 20 March 2007)
Scandinavian Journal of Public Health, 2007; 35: 577­584
ISSN 1403-4948 print/ISSN 1651-1905 online/07/060577-8 # 2007 Taylor & Francis
DOI: 10.1080/14034940701362194
 2007 Associations of Public Health in the Nordic Countries Regions. All rights reserved. Not for commercial use or unauthorized distribution.
at Uppsala Universitetsbibliotek on April 25, 2008http://sjp.sagepub.comDownloaded from
more explanations, and more responses to questions
at the level of speech of the patients. On the other
hand, physicians seem to be more likely to reject
medical explanations from female patients [5], and
female patients were spoken to in a less interested
fashion than male patients by physicians of both
sexes [6]. More women than men reported that they
felt that physicians talked down to them (25% vs.
12%) and told them their problems were only in
their heads (17% vs. 7%) [7].
An optimal encounter in clinical medicine rests on
an interpretive meeting between the patient and the
professional [8]. Today, many medical consultations
include handling aspects of sickness certification, a
task many physicians experience as problematic
[9,10]. Thus, such consultations may cause quandaries
that could be expected to complicate encounters.
From the perspective of long-term sickness
absentees these encounters could be expected to be
of extreme importance, for instance economically, as
they need a certificate for sickness benefits.
However, the specific perspective of the sickness
absentees ­ in contrast to all patients ­ has seldom
been highlighted, with a few exceptions [11­14].
Svensson et al. [1] discussed the importance of
interaction with professionals who have some power
over a patienťs future, such as the professionals you
meet when sickness absent, in relation to RTW. The
interaction may evoke social emotions such as pride
or shame, which could be expected to result in
empowerment or disempowerment, respectively,
which in turn, hypothetically, could be related to
RTW. From a feminist frame of reference Werner &
Malterud [15] explored efforts made by female
patients to be believed, understood, and taken
seriously when consulting physicians. They emphasize
the relationship between dignity and shame,
power and disempowerment for female patients with
medically unexplained disorders.
In a review [16] of studies on patient satisfaction it
was pointed out that the instruments used for data
collection often are biased toward issues that
concern health professionals rather than patients
and that researchers should pay greater attention to
expressions of dissatisfaction than to refine instruments
which repeatedly show high levels of satisfac-
tion.
Possible gender differences in experiences of
negative encounters among sickness absentees are
of special interest because of women's higher sick
leave and slower RTW rate [17,18] and because a
number of women ``doctor-shop'', indicating dissatisfaction
with encounters within healthcare [19­
21].
Aim
The aim was to analyse gender differences in
sickness absentees' experiences of negative encounters
with healthcare professionals.
Material and methods
A cross-sectional population-based questionnaire
survey was conducted.
Study population
The study population comprised a random sample
of 10,042 individuals from the 22,158 persons in
Sweden who, on 31 January 2003, were aged 20­64
years, had an ongoing sick-leave spell for 6­8
months, and had not been granted part-time
disability pension. The sample was drawn from the
register of all people on sick leave kept by the
National Social Insurance Board. Of these, before
sending out the questionnaire, Statistics Sweden
excluded 58 persons due to death or emigration.
Questionnaire and respondents
A comprehensive questionnaire regarding perceptions
of contacts with professionals was constructed,
based on findings from qualitative [11,13,22] and
quantitative studies [12,14], clinical experiences,
theoretical considerations [1], and small pilot
studies. The questionnaire comprised questions in
terms of statements regarding experiences of positive
and negative encounters with healthcare and social
insurance professionals, the emotions such contacts
evoked, and whether positive and negative contacts
might promote or hinder RTW. A few questions on
demographics were also included (e.g. level of
education). Data on gender, age, and ethnicity were
obtained from the National Social Insurance Board
(Table I). The questionnaire took approximately
one hour to complete. It was administrated by
Statistics Sweden in April 2004. A reminder was sent
to non-responders after one week and again after
another 10 days.
Data on 5,802 respondents (58%) were available
for the analyses. In general, the response rate was
higher among females (pv0.001), native Swedes
(pv0.001), and individuals aged 50­64 compared
with younger people (pv0.001) (see Table I).
In the present study answers to the questions on
negative encounters with healthcare were analysed.
Respondents were first asked whether they had
experienced such encounters in connection with
their sickness absence. Individuals with negative
578 M. Upmark et al.
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experiences were requested to rate 23 statements on
negative encounters (listed in Table III), by choosing
one of four alternatives: ``agree completely'',
``agree to a large extenť', ``agree to a limited
extenť', or ``do not agree''. The 110 individuals
who had not answered either the first question or any
of the statements were excluded.
Statistical analyses
Separate mean values, stratified on gender, for the
answers to each statement were calculated. Logistic
regression analyses were carried out to identify
possible associations between gender and experiences
of different aspects of negative encounters. For each
statement the answers were dichotomized into
``agree'' (answer ``agree completely'', ``agree to a
large extenť', or ``agree to a limited extenť') and ``do
not agree''. The odds ratio (OR) for agreeing among
women was related to the corresponding odds ratio
among men. Persons who in the first question claimed
no negative encounters were, for each statement,
included as disagreeing. In a second step multiple
logistic regression analyses were used to adjust for
possible association with age, ethnicity, and level of
education. Analyses were performed where age was
regarded as continuous; ethnicity was divided into
four categories ­ born in: Sweden (1), other Nordic
(2), Asian, African or South American (3), and other
countries (4), i.e. people born in other European
countries and people born in North America. Level of
education was divided into those with only compulsory
school, those with education from high school,
and those who had attended university.
A p-value of v0.05 was regarded as statistically
significant and 95% confidence intervals (CI) were
calculated. The chi-squared test was used to test for
significant differences between proportions (e.g.
gender).
Results
Almost one-third (32%) of the female respondents
and one-quarter of the male (24%), respectively,
agreed with one or more of the different statements
on experiences of negative encounters. The great
majority (91% among women and 87% among men)
of the 1674 individuals who had had negative
experiences also indicated experiences of positive
encounters (Table II). Two-thirds of the respondents
mentioned physicians as the profession in the
encounter perceived as most negative (71% by
women and 62% by men) followed by ``do not
know the profession'' (12%) and nurse (8%).
Younger persons (20­29 years) more often reported
negative encounters than middle-aged (30­49) and
older (50­64) as did persons with higher education
(see Table II). A majority among both women and
men with experience of negative encounters had
agreed with 10­18 of the statements.
In general, there were great similarities in the
response pattern between women and men: they had
encountered the same dimensions of negative
encounters often or vice versa (Table III).
However, for a number of items women agreed
more strongly than men (figures not reported) and
more women had experienced different types of
negative encounters; ORs ranged from 1.19 to 1.71,
significant for all 19 out of 21 items. For nine of
these the OR was 1.60 or above: ``Not believed what
I have saiď', ``Treated me with indifference'',
``Doubted my complaints'', ``Regarded me as
stupiď', ``Been irritated/impatienť', ``Treated me
with disrespecť', ``Not listeneď', ``Interrupted me'',
and ``Made unreasonable demands'' (see Table III).
When adjusting the ORs for age, ethnicity, and
level of education significant gender differences were
still found for 14 of the statements, indicating that
there is a gender difference in perception of the
encounter, regardless of the patients' age, ethnicity,
or level of education (see Table III).
Discussion
Some 29% of the long-term sickness absentees had
experienced negative encounters with healthcare
professionals. There were no large differences in
what type of encounters larger number of women
and men had perceived often or less often; however,
women more frequently reported experiences of
Table I. Demographic factors regarding study population and
respondents.
Study population
n (%)
Respondents
n (%)
All 10,042 5,802
Sex
Women 6,031 (60) 3,698 (64)
Men 4,011 (40) 2,104 (36)
Age
20­29 882 (9) 460 (8)
30­39 2,307 (23) 1,177 (20)
40­49 2,605 (26) 1,424 (25)
50­59 2,901 (29) 1,825 (31)
60­64 1,347 (13) 916 (16)
Ethnicity
Swedish 8,439 (84) 4,997 (86)
Non-Swedish 1,603 (16) 805 (14)
Gender differences in negative encounters with healthcare 579
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negative encounters, also when adjusting for age,
ethnicity, and level of education. For those statements
where no gender differences were found only
very few had agreed.
Influence of gender on perceived encounter
Another study of sick-listed persons' contacts with
health professionals has shown that women rated their
contacts as more positive [12]. However, in the
persent study the experiences of women to a greater
extent than those of men reflected disrespectful
behaviour of the health professional such as having
been encountered with anger, distrust, doubt, blame,
impatience, or been treated as stupid. One of many
explanations could be women's higher utilization rate
of healthcare thus increasing their chances of experiencing
both negative and positive encounters.
Expectations are generally considered to be an
important determinant of patient satisfaction [16]
and presumably also of how encounters are perceived.
Gendered attitudes in search for help, i.e.
women's hope for help compared with a more
demanding attitude of men [23], might affect how
the encounter was perceived. Consequently, women
could perceive the same encounter more positively
than men since their expectations are lower.
Items directly reflecting a behaviour considered as
nonchalant and disrespectful ­ ``Treated med with
indifference'', ``Regarded me as stupiď', ``Was
angry/unpleasanť', and ``Treated me with disrespecť'
­ were all more frequently reported by
women. Moreover, almost one-fourth of the women
(23%) perceived that they were regarded as stupid.
To perceive that the encounter is characterized in a
nonchalant and disrespectful way might not only
induce shame but also be detrimental to rehabilitation
efforts [22].
``Not believed what I have saiď' and ``Doubted
my complaints'' were found to be two of the other
most gender discriminating items. Klanghed et al.
[13] found from focus-group interviewees that
encounters with professionals were considered as
positive when the interviewees were believed in and/
or taken seriously. As a contrast, a number of studies
have illustrated how women report that they
experience that physicians distrust them ­ which
seems to be related to disorders common among
women usually described as illnesses with no clearcut
pathological findings [11,19,21,23]. In a study
[11] on female patients' consultation experiences
sick-listed women used different strategies to catch
physicians' attention and to uphold self-respect,
whereby physicians' attitudes, described as ignoring,
disregarding, and rejecting, may be intensified by the
patients' attempts to question and discuss assumptions.
A° sbring & Na¨rvinen, in a qualitative study
[21] of female, mainly sick-listed patients diagnosed
with chronic fatigue syndrome or fibromyalgia,
found that the women's credibility was questioned
Table II. Demographic factors regarding respondents with experience of negative and positive encounters.
A B C
Total number of
respondents
Respondents with experience
of negative encounters
n (% of A)
Respondents with experiences of
negative and positive encounters
n (% of B)
All 5,802 1,674 1,498
Sex
Women 3,698 1,171 (32) 1,061 (91)
Men 2,104 503 (24) 437 (87)
Age
20­29 460 233 (51) 192 (82)
30­49 2,601 948 (36) 858 (91)
50­64 2,741 493 (18) 448 (91)
Ethnicity
Swedish 4,997 1,416 (28) 1,277 (90)
Other 805 258 (32) 221 (86)
Education
Compulsory school 1,759 395 (22) 345 (87)
High school 2,423 783 (32) 689 (88)
University 1,564 485 (31) 455 (94)
Unknown 56 11 (20) 9 (82)
580 M. Upmark et al.
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by the caregivers, particular by physicians, who
seemed to regard them as malingerers.
``Not listeneď' and ``Interrupted me'': More
women than men confirmed that they had been
interrupted. That gender is associated with pattern
of interruptions with female patients being more
interrupted (by both female and male physicians) is
in line with a study of speaking and interruptions
during primary care visits [24]. Interruptions could
be interpreted as domination and control but also as
physicians being more eager to receive additional
information [25].
It is positive that only a small percentage had
experienced inappropriate sexual encounters or
being threatened or harmed physically. Nevertheless,
2­5% of the women and the men had had such
experiences. Even regarding inappropriate sexual
encounters, as many as 116 persons had experienced
such encounters.
Role of the professional: empowerment instead of
belittlement
The encounters perceived by the sickness absentees
give topical interest to the concept of empowerment,
which could be seen as the opposite of oppression
[26]. Malterud & Hollnagel [27] propose that a
focus on women's self-assessed personal health
resources can be a part of an empowering strategy.
By recognizing the suffering of women with pain and
their strengths the medical encounter can prevent
further disempowerment [28].
Another way, proposed by Werner & Malterud
[15], in which physicians can help patients transform
Table III. Number of women and men agreeing to statements on experiences of negative encounters among sickness absentees and odds
ratios (OR) with 95% confidence intervals (CI) for women vs. men (n55,692).
Statement
Agreed (%) Gender reference5men
Adjusted for age, ethnicity, and
education
women men OR 95% CI OR 95% CI
Doubted my capacity to
work
20 16 1.33 1.15­1.54 1.14 0.98­1.32
Questioned my desire/
motivation to work
23 17 1.51 1.32­1.74 1.27 1.10­1.47
Not believed what I have
said
26 18 1.64 1.43­1.88 1.38 1.20­1.60
Treated me with
indifference
28 19 1.66 1.45­1.89 1.37 1.19­1.57
Doubted my complaints 26 18 1.63 1.42­1.87 1.37 1.19­1.58
Regarded me as stupid 23 15 1.68 1.46­1.94 1.39 1.19­1.62
Rejected my suggestions and
solutions
24 17 1.57 1.37­1.81 1.30 1.12­1.50
Was stressed/Not taken time
for me
27 19 1.53 1.34­1.74 1.27 1.10­1.45
Was irritated/impatient 25 17 1.58 1.38­1.81 1.31 1.14­1.52
Was angry/unpleasant 22 15 1.65 1.43­1.91 1.39 1.19­1.61
Treated me with disrespect 26 18 1.67 1.45­1.91 1.37 1.18­1.58
Threatened me 5 4 1.19 0.91­1.55 1.01 0.77­1.33
Not listened 26 17 1.71 1.48­1.96 1.41 1.22­1.63
Harmed me physically 4 4 0.98 0.74­1.30 0.87 0.65­1.17
Was too impersonal 24 17 1.55 1.35­1.78 1.28 1.10­1.48
Not kept our agreements 14 11 1.33 1.13­1.57 1.10 0.92­1.31
Blamed me for my condition 15 10 1.49 1.26­1.76 1.22 1.02­1.46
Sexually inappropriate
behaviour
2 2 0.71 0.60­1.42 0.79 0.51­1.23
Not explained things so that
I could understand
13 11 1.29 1.09­1.54 1.12 0.94­1.34
Interrupted me 20 13 1.67 1.43­1.94 1.40 1.19­1.64
Made unreasonable
demands
21 14 1.65 1.42­1.92 1.39 1.19­1.63
Not made enough demands 8 7 1.17 0.94­1.44 0.99 0.80­1.23
Not let me take
responsibility for myself
16 12 1.38 1.17­1.61 1.16 0.99­1.37
Significant ORs in bold.
Gender differences in negative encounters with healthcare 581
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vulnerability into strength, instead of increasing a
feeling of disempowerment, is by admitting the
shortcomings of medical knowledge. Thereby the
blame can be transformed to the medical discipline
instead of the individual patient who presents
symptoms or reveals behaviour that does not fit with
biomedical expectations of what illness is and how it
should be performed.
Asymmetry of the medical relationship
Overall, a larger percentage of the female absentees
in our study expressed what can be interpreted as
experiencing a subordinate position in the eyes of the
professionals. Besides the interpersonal relation in
the communication between the sick-listed and the
professional their roles could be seen as interactional
strategies that link social structure to social interaction,
as proposed by Fisher & Groce [5]. Thus, the
encounter between health professionals and sicklisted
persons comprises a contextual power imbalance
[29,30] shaped by the roles of health professionals
and their place in the social structure, and
laymen. The medical interview sustains both the
institutional authority and status of physicians and
the reality of genders. In encounters with sick-listed
persons the gate-keeper role regarding sickness
benefits could be expected to enhance the power
imbalance still more.
When interpreting gender differences in encounters
with healthcare professionals we are prone to
agree with Hammarstro¨m & Ripper [31, p 289]: ``a
power perspective in public health can bring a more
comprehensive and subtle understanding of the
multiple and contradictory elements of gender and
other relations of power that impact on the health
status of populations''.
Methodological considerations
Strengths of the study are that the sample is
population based and large (w10,000 long-term
sickness absentees). Previous studies are small and
mainly qualitative [11­13]. The larger proportion of
women in the study population is in line with the
higher sick-leave rate of women [18]. The relatively
low response rate (58%) is a limitation, however,
comparable to other population-based questionnaire
surveys to long-term sickness absentees [14,18].
Non-participation might have been due to severe
diseases, psychosocial problems, or language difficulties;
due to the inclusion criteria (long-term
sickness absence) the rate of such persons was
higher than in the general population [18]. We do
not know in which direction potential selection
biases caused by different experiences of healthcare
might go. There are indications that the result is to
some extent selective in so far as groups with lower
response rates also reported more negative encounters,
especially the immigrants. This implies that the
findings of negative encounters might be under-
estimated.
As there were no open-ended questions we might
have missed important aspects of encounters.
However, the questions were based on previous
interview studies with absentees and consequently
were not biased towards issues that concern management
and the health professionals [16].
At large it could be expected that the answers are
reported less negatively than they would have been
with the use of another method [32]. Because of this
we included those ``agree to a limited extenť' with
``agree'' in the regression analyses.
Just as patient survey measures of satisfaction can
be understood as measures of patient characteristics,
physician characteristics, and relationship characteristics
[33], measures of perceived negative encounters
with health professionals among long-term
sickness absentees might be interpreted in a similar
way. To give a more comprehensive picture including
the perceptions of both the sickness absentees
and the health professionals it is necessary to use
another design. Fossum & Arborelius have explored
meetings between physicians and their patients by
using video-taped consultations. The analyses of the
comments made by the patients have been considered
helpful in clarifying the difference between
encounters experienced as satisfactory or unsatisfactory
[34­36].
The gender differences in result can probably be
generalized also to other long-term sickness absentees
in Sweden, and possibly also in other Western
countries. However, culturally defined structures of
power reflected in relations between healthcare
professionals and patients as well as between women
and men could influence the results. Nevertheless,
the subordination of women and the power imbalance
between patient and physicians [30] are
universal phenomena. The power imbalance may
be strengthened when economic aspects are involved
as in these encounters.
Conclusion
Many of the experiences of negative encounters with
healthcare professionals, which could mirror disrespectful
behaviour, were frequently reported by
both women and men. There were no large gender
differences in type of encounters; however, experiences
of negative encounters among long-term
582 M. Upmark et al.
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sickness absentees were more frequently reported by
women. Since women's high sick-leave rates and low
RTW rates in most countries are seen as problem
their subjective experiences are an important factor
to consider. One important effort among professionals
in healthcare could be to shift focus towards a
more empowering professional role, thereby reaching
the optimal interpretive meeting [8] between the
patient and the professional. To gain a more
comprehensive picture of the gender differences in
reports of negative encounters further studies are
needed.
Acknowledgements
Financial support was provided by the Swedish
Council for Working Life and Social Research and
the Swedish National Social Insurance Board.
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