562598

research-article2014
SJP0010.1177/1403494814562598Gender inequality and women’s healthF. Eek and A. Axmon

Scandinavian Journal of Public Health, 2015; 43: 176–182

Original Article

Gender inequality at home is associated with poorer health for women

Frida Eek1 & Anna Axmon2

1Department of Health Sciences, Lund University, Lund, Sweden, and 2Division of Occupational and Environmental
Medicine, Lund University, Lund, Sweden

Abstract
Background: As more women have joined the work force, the difference in employment rate between men and women has
decreased, in Sweden as well as many other countries. Despite this, traditional gender patterns regarding, for example,
responsibility for household duties still remain. Women are on sick leave more often than men, and previous studies have
indicated that an unequal split of household responsibilities and perceived gender inequality could be associated with negative
health outcomes. Aims: The aim of the present study was to explore whether an unequal distribution of responsibilities in
the home was related to various health related outcomes among women. Methods: A sample consisting of 837 women living
in a relationship, and working at least 50% of full time, responded to a questionnaire including information about division
of responsibilities at home as well as various psychological and physiological health related outcomes. Results: The results
showed that women living in relationships with perceived more unequal distribution of responsibility for house hold duties
showed significantly higher levels of perceived stress, fatigue, physical/psychosomatic symptoms, and work family conflict
compared with women living in more equal relationships. They also had significantly increased odds for insufficient time for
various forms of recovery, which may further contribute to an increased risk of poor health. Conclusions: Although an
increasing employment rate among women is valuable for both society and individuals, it is important to work
towards greater gender equality at home to maintain this development without it having a negative effect on
women’s health and well-being.

Key Words: Equality, gender, work–family conflict, inequality

Introduction
Over the last decades, an increasing number of
women, in many parts of the world, have joined the
work force. Today, the majority of Swedish parents,
mothers and fathers, are working. The employment
rate among Swedish women (16–64 years) has
increased from 68% in 1976 to 72% in 2004. The
difference in employment rate between men and
women has, during the same period, decreased from
a 20% to 3% lower employment rate among women
[1]. In 2010, Sweden was one of the countries in EU
with the highest employment rate among women
aged 20–64 years [2]. Swedish parents were employed
to an even higher extent; in 2008, 83% of all children
aged 0–17 years had an employed mother and 93%
had an employed father [3].
Women are on sick leave more often than men [4].
Higher sick leave among women is not only found in
Sweden, but also in many other European countries
[5]. In Sweden, among employees in the private
sector, psychological/psychiatric diagnoses are the
most common reason for a long (<15 days) sick leave
[4]. Psychiatric diagnoses are also the most common
reason for longer sick leave among women in general,
both 1–2 years before, and up to 7 years after the
birth of a child [6].
During the 1980s and 1990s, the gap in sick leave
between men and women increased [5]. One possible
explanation for this increase in difference is that
women work more today than they did 30 years ago.
Since the turn of the millennium, the gap has

Correspondence: Frida Eek, Department of Health Sciences, Lund University, PO Box 157, SE-22100 Sweden. E-mail: frida.eek@med.lu.se

(Accepted 12 November 2014)

© 2014 the Nordic Societies of Public Health
DOI: 10.1177/1403494814562598

remained more constant, on a level where the sick
leave among women is about 80% higher than among
men [6]. The reason for the higher sick leave among
women is not completely clear. However, having
children is a contributing factor to the risk of sick
leave among women. Women with children under the
age of 12 years have higher risk of sick leave than
men in the same situation [4]. There is a marked
increase in risk for sick leave for women when the
child is 2 years old [5,6]. This period often coincides
with the period when mothers have returned to work
after parental leave. The increased risk for sick leave
for mothers compared to fathers then remains
for about 17 years after the birth of the child. Also,
previous studies have shown that increased domestic
work-related strain is associated with various negative
mental health outcomes, such as lower mental health,
vitality and self-rated health [7, 8].
An international comparison between women in
five different countries showed that Swedish women
reported the highest level of interference between
paid work and household demands, which was sup-
posed to at least partly be due to Swedish women
more often having qualified and demanding jobs than
women in other countries [9]. This has been associ-
ated with various negative health outcomes, such as
depression, poor self-rated health, emotional exhaus-
tion and burnout [10–12].
Traditional gender patterns in the split of house-
hold chores, that is the woman takes the larger
responsibility for children and household work, have
been shown to be evident also in couples where both
work full time [13]. Swedish women have reported
more work overload, stress and conflict between work
and family demands than men, despite equal levels of
education [13]. This has also been found in other
studies, and the negative outcomes seem to increase
with the number of children at home, with a peak for
women between 35 and 39 years [14]. An unequal
split of household responsibilities and perceived
gender inequality between the two persons in a
relationship have also been found to have a negative
effect on psychological distress and depression
[8,15–17] as well as musculoskeletal pain [18].
Aim
The aim of the study was to explore whether an
unequal distribution of responsibilities in the home
was related to various health-related outcomes
among women. More specifically, we aimed to
examine whether women living in unequal relation-
ships differed from women living in more equal
relationships, in terms of perceived stress, fatigue,
self-rated health, physical/psychosomatic symptoms,
Gender inequality and women’s health   177
work–family conflict, work engagement, work- and
life satisfaction, and time for recovery.
Methods
Study sample
The sample consists of women participating in a
larger questionnaire survey study, containing occu-
pationally active men and women with small
children [19]. The original sample consisted of
parents whose youngest child was either 2 years old
or 7 years old. The parents were selected though a
random sampling procedure from the Perinatal
Revision South (PRS), a medical birth registry that
covers all births in Swedish southern healthcare
region during the relevant period.
The study sample included in the present study
consisted of 837 working women living in a relation-
ship with either the biological father of their youngest
children (96.7%) or another partner (3.3%). All
participants worked at least 50% of full time working
hours. Data collection was performed between
October 2008 and February 2009.
Measures and definition of variables
All participants responded to a postal questionnaire
survey containing questions regarding home, family
and work place factors along with well-established
instruments measuring a variety of stress- and health-
related dimensions. The questionnaire also included
questions about the division of daily household duties
and child care.
The questions about household duties included
‘Who, of you and your partner, does the most of the
daily household duties (excluding child care)?’ with
response alternatives: (1) ‘My partner does much
more’; (2) ‘My partner does a little more’; (3)’We do
approximately equally much’; (4) ‘I do a little more’;
(5) ‘I do much more’. In the present study, we defined
‘unequal’ division of household duties as response
alternative 5: ‘I do much more’.
To measure the outcome variables in the present
study, a number of well-established instruments
for measures of subjective stress and well-being
(including fatigue and physical/psychosomatic
symptoms), work-related stress and engagement,
and work–family conflict were used. These are
described in detail below. In addition, the question-
naire included questions about recovery and leisure
time activities, also used as outcome or independent
variables in the current study.
Work time was measured and defined as either full
(35+ hours/week) or part time, and educational level
178    F. Eek and A. Axmon
was measured on five levels, from primary school to
university >3 years.
Subjective stress and well-being
Subjective global stress was measured with the
Perceived Stress Scale (PSS) [20]. PSS contains 14
questions regarding the experience of different
aspects of global stress during the last month. Each
question is rated from ‘never’ (0) to ‘very often’ (4).
The mean score of the 14 items was used in the
analyses, hence a possible score range from 0 to 4.
Physical/psychosomatic symptoms were measured
by the Lund Subjective Health Complaints (LSHC),
which is rather similar to the UHI/SHC scale [17].
The LSHC is an inventory assessing the intensity of
13 common health complaints experienced during
the last 30 days. These include headache, dizziness,
forgetfulness, back pain, neck–shoulder pain and
stomach pain. For each health complaint, the parent
was to indicate the frequency during the preceding
month, from ‘never’ (1) to ‘always (almost every day)’
(5). In the present study, a global measure represent-
ing the mean score of all items was used (possible
score range 0–5).
General physical and mental self-rated health was
measured by SRH-7, a single item asking about the
subjective perception of current physical and mental
well-being, measured from ‘very bad, could not
feel any worse’ (1) to ‘very good, could not feel any
better’ (7) [21]).
Work-related fatigue was assessed by the Swedish
Occupational Fatigue Inventory, SOFI-20 [22,23].
SOFI-20 measures work-related fatigue from a
multi-dimensional perspective including five differ-
ent dimensions of fatigue: lack of energy, lack of
motivation, physical exertion, physical discomfort
and sleepiness. Each item was assessed for the end of
a typical workday and rated from ‘not at all’ (0) to ‘to
a very high extent’ (6). In the present study, a global
measure of the mean score of the 20 items was used.
Satisfaction with general life- and work situation
was measured by two single questions, asking ‘How
satisfied are you, in total, with your work situation?’
and ‘How satisfied are you, in general, with your
private life situation (family/leisure time)?’ with seven
response alternatives from ‘Very dissatisfied’ (1) to
‘very satisfied’ (7).
Work stress and engagement
Work stress was measured with the General Nordic
Questionnaire for Psychological and Social Factors
at Work (QPS Nordic)-36 [24] and work engagement
was assessed using the Utrecht Work Engagement
Scale (UWES) [25]. UWES is a 17-item instrument
measuring work engagement, including the three
subscales Vigour, Dedication and Absorption. The
mean score of each subscale was analysed in the pre-
sent study, resulting in three subscale scores with a
total score that ranged between 0 and 6. QPS
Nordic-36 is the short version (36 items) of the QPS
Nordic [24]. This instrument has been developed in
Sweden, Denmark, Finland and Norway. It contains
a wide variety of dimensions such as work-related
demands and control, role expectations, social inter-
action, leadership, group work and organizational
climate. We used the mean scores of the 4 work-
related demands and six control items, as well as the
one stress item ‘Have you felt stressed lately?’
(response range from 1, not at all, to 5, very much)
variable as measures of different aspects of work-
related stress as dependent variables in our analyses.
Work–family conflict
We used an eight-item inventory covering both
time- and strain-based conflict between work and
family. Two different dimensions of work–family
interference were measured: work-to-family conflict
(WFC), that is spill-over effects from work on family
life, and family-to-work conflict (FWC), that is
spill-over from effects from family obligation and
demands on working life, with four items for each
dimension [26]. Response alternatives ranged from
‘do not at all agree’ (1) to ‘agree completely’ (5). The
mean score of the four items for each dimension was
used in the present study, resulting in two subscores
with a possible score range from 1 to 5.
Recovery and leisure activities
The questionnaire also included a study-specific
questionnaire regarding the experience of time for
different recovery and leisure activities. The questions
asked about whether the respondents experienced
having sufficient time for physical exercise, social
intercourse with partner, children, relatives, friends,
hobbies and relaxation. The response alternatives
were ‘yes’ (0), ‘partly but I desire more’ (1), ‘no, far
from enough’ (2) and ‘not interested in this’ (3).
These variables were dichotomized into enough
time for the activity (response alternative 0) versus
insufficient time for it (response alternative 1 and 2).
Statistical analysis
The statistical analyses aimed to explore possible
differences between women experiencing unequal
or equal distribution of household duties in their
relationship (independent variable), regarding sub-
jective measures of stress and well-being, work
engagement, work–family conflict and insufficient
 Gender inequality and women’s health   179
Table I.  Descriptives of participants.

All Equal Unequal

  N=837 N=553 N=284

Age (mean/SD) 36.7/5.12 36.4/5.03 37.3/5.3

Education % (n) (n=822)  
≤9 years 1.7 (14) 1.8 (10) 1.4 ( 4)
10–11 years 9.2 (76) 7.6 (41) 12.5 (35)
12–13 years 19.8 (163) 18.5 (100) 22.4 (63)
University; <3 years 13.5 (111) 13.5 (73) 13.5 (38)
University 3+ years 51.3 (422) 54.9 (297) 44.5 (125)
Other 4.4 (36) 3.7 (20) 5.7 (16)
Age of youngest child %, (n) (n=837)  
7 years 50.1 (418) 47.0 (260) 55.6 (158)
2 years 49.9 (419) 53.0 (293) 44.4 (126)
Work time %, (n) (n=836)  
Full time (<90%) 45.2 (378) 48.8 (283) 33.6 (188)
Part time (50–90%) 54.8 (458) 51.2 (270) 66.4 (95)

*Unequal’ means women taking much more responsibility for household duties than their partner. ‘Equal’ means women taking a little
more, equally much (or less) responsibility as their partner.

time for recovery (dependent variables). All analyses Ethics

were performed in PASW/SPSS version 20.
Differences in continuous/scale outcome variables
(or ordinal scales treated as metric; PSS, self-rated
health (SRH), SOFI, LSHC, QPS, UWES (three
subscales), FWC and WFC, and life- and work satis-
faction) were analysed using separate univariate anal-
yses of variance (ANOVAs). The distribution
of outcome variables was not perfectly normal;
however, there were no outliers and, due to the large
sample size and in most cases approximately
symmetric distribution, we considered the require-
ments for the ANOVA test to be fulfilled. To explore
potential effect modifications from work time
(part- or full time), the interaction effect between
perceived inequality and work time was introduced
and tested in the separate models. Insufficient time
for recovery and leisure activities, defined as a binary
outcome was analysed by logistic regression.
Odds ratios (ORs) and 95% confidence intervals are
presented. All analyses were adjusted for work time
(full- or part time), age of the youngest child (2 or 7
years) and educational level. Further exploratory
ANOVAs, including more potential confounders,
such as number of children, having a child with
special needs and household income (seven catego-
ries), showed that the inclusion of these variables did
not affect either estimated group differences or p-
values, and hence they were not included in the final
models.
p-Values ≤ 0.05 were considered significant.
The number of missing individuals in the different
outcome measures was between five (0.6%) (UWES)
and 18 (2.2%) (‘satisfaction with life situation’,
‘insufficient time for sleep’).
The project was approved by the Ethics Committee
at Lund University (Ref H15: 215/2008), and con-
forms to the provision of the Declaration of Helsinki.
Results
Women living in relationships with perceived more
unequal distribution of responsibility for household
duties showed significantly higher levels of perceived
stress, fatigue, physical/psychosomatic symptoms
and work–family conflict than women living in more
equal relationships (Table II). They also reported
higher levels of work-related stress and work-related
demands. Moreover, they showed significantly lower
levels of general well-being, and a lower satisfaction
with their general life situation (Table II). There were
no significant differences regarding work-to-family
conflict or satisfaction with work situation. Neither
did they differ in level of work engagement (any of
the three subscales) or in the perception of work-
related control.
There were no significant interaction effects
between perceived inequality and work time, indi-
cating that the association between unequal distribu-
tion of responsibility and poorer health and well-being
did not differ depending on whether the women
worked full- or part time.
Women living in more unequal relationships also
had significantly increased odds for experiencing
insufficient time for relaxation, exercise, hobbies,
friends, relatives and partner, compared with women
living in more equal relationships (Table III). The
odds for insufficient time for the children and for
sleep were not significantly increased.
180    F. Eek and A. Axmon
Table II.  Perceived stress, subjective health complaints, self-rated health, fatigue, life satisfaction, work related stress, work engagement and
work–family interference among women living in relationship with equal or unequal share of house hold duties.

Equal (n=553) Unequal (n=284) p*

  Mean 95% CI Mean 95% CI

Perceived stress (PSS) 1.93 1.86–2.01 2.11 2.02–2.19 <0.001

Subjective health complaints 1.88 1.81–1.96 2.06 1.97–2.15 <0.001
(SHC)
Self-rated health (SRH) 4.71 4.56–4.87 4.39 4.21–4.57 <0.001
Work-related fatigue (SOFI) 1.60 1.46–1.74 1.89 1.72–2.05 0.001
Satisfaction with life situation 5.47 5.28–5.65 4.87 4.66–5.09 <0.009
Satisfaction with work situation 4.96 4.77–5.16 4.84 4.86–5.07 0.250
Work-related stress:  
QPS control 3.30 3.21–3.39 3.22 3.12–3.33 0.134
QPS demands 2.43 2.34–2.52 2.62 2.52–2.73 <0.001
QPS stress 3.07 2.92–3.23 3.34 3.16–3.51 0.003
Work engagement:  
UWES vitality 3.75 3.64–3.86 3.73 3.60–3.86 0.692
UWES dedication 3.90 3.77–4.04 3.82 3.67–3.98 0.311
UWES absorption 3.36 3.24–3.48 3.44 3.30–3.58 0.265
Work–family interference:  
Work to family spill-over (WFC) 2.40 2.29–2.52 2.47 2.34–2.61 0.275
Family to work spill-over (FWC) 1.99 1.88–2.09 2.32 2.19–2.45 <0.001

*p-Value from ANOVA, adjusted for work time, age of youngest child and educational level.
Score ranges: PSS 0–4, SHC 0–5, SRH 1–7, SOFI 0–6, Satisfaction 1–7, QPS 1–5, UWES 0–6, Work family interference 1–5.

Table III. OR (95% CI) for experience of insufficient time for power and impact among men and women, in society
different recovery- and leisure activities among women with per- as well as at home.
ceived unequal compared to more equal distribution of house hold
duties. However, it appears that the development towards
gender equality at home has not completely followed
Insufficient time for OR 95% CI development in the labour market. More women than
Sleep 1.39 0.91–2.13 men still take the largest responsibility for household
Relaxation 1.99 1.45–2.72 work and child care, despite also taking equal part in
Exercise 1.50 1.10–2.04 the labour market. This persistent unequal role divi-
Hobbies 1.67 1.23–2.27 sion seems to have consequences in terms of impact
Friends 1.55 1.07–2.24
on women’s health and well-being. Women are more
Relatives 2.02 1.26–3.26
Partner 1.55 1.08–2.21 often on sick leave than men, a gender inequality
Children 1.24 0.78–1.97 which increases after the birth of a child [4–6], a time
period when also traditional gender roles are known
Adjusted for work time, age of youngest child and educational to be strengthened with increased inequality in the
level.
division of household responsibilities as a conse-
quence. It is worth noting that sick leave among par-
Discussion ents, mothers and fathers, only relates to their own
Even though there are many structures on the labour sickness. When the child is sick, Swedish parents have
market where gender inequality is still evident, the what is called ‘leave for temporary care of a child’,
equality in terms of employment rate and participa- which is not registered as sick leave for the parent.
tion in the labour market has increased markedly Our results showed that women who take the larg-
during the last decades in Sweden and in many other est responsibility for household work also report
countries. This increasing gender equality in terms of more stress, lower subjective well-being, and more
increasingly equal employment rate among men and fatigue and subjective health complaints. They also
women is generally considered positive. That women report lower satisfaction with their general life situa-
become more active on the labour market has many tion than women in more equal relationships.
positive effects in society as well as for the women’s One potential link in this association may be that
individual situation and possibilities. The health women in perceived unequal relationships also report
effects associated with active employment are well less time for relaxation and also leisure activities such
known [27], and more women in the labour market as exercise, hobbies and social intercourse with
increases the possibility of a more equal share of friends. These activities may serve as important

sources of recovery, which is an important clue in the
prevention of poor health effects as a result of the
stress experienced. These women also report higher
levels of both general- and work-related stress.
Regarding work-related stress, the stress experienced
seems to stem from higher demands placed on these
women than women living in more equal relation-
ships. The experience of work-related control did not
differ. Even though the QPS measures work-related
stress, this experience is not sharply marked off from
private life. The women in perceived unequal
relationships also report higher levels of family to
work spill-over, which may add to the burden of
work-related demands experienced.
Apart from the higher experience of work-related
stress, more particularly work-related demands,
work-related factors do not seem to differ between
women with more or less equal relationships. Their
satisfaction with work does not differ significantly,
and there is no significant difference in work engage-
ment, either regarding vitality, engagement or
absorption. A lower interest or engagement in their
job could perhaps have been an indication that the
unequal division of house hold works and responsi-
bility reflects a volunteer and possibly desired
role division, with a volunteer down grading of the
woman’s work engagement and an upgrading of the
home responsibility. Though, this seemed not to
be the explanation since the women in unequal rela-
tionships showed no less work engagement than
women in more equal relationships. Even though
part of the increased responsibility among women
could be explained by more women working part
time, especially when children are young, that is not
the complete explanation since the unequal share of
household duties is present also in couples where
both work full time [28]. In the present study, we did
not find any interaction effects between perceived
inequality and work time with respect to health out-
comes. This indicates that the effect of unequal role
division persists regardless of work time. The finding
that the women in perceived unequal relationships
experience similar work engagement, and are equally
satisfied with their work situation, also contributes
to the explanation that the difference in health, well-
being and time for recovery should depend on a
general level of negative affectivity in this group.
Also, these women do not report insufficient time
for sleep or intercourse with children. The latter
may be explained by the fact that these women as a
consequence of having a larger responsibility for
household duties and less time for leisure activities
spend more time at home, where the children are.
A limitation of the study is the rough measure of
‘equality’, based on one single question regarding
division of responsibility for household duties. That a
Gender inequality and women’s health   181
woman takes much larger responsibility at home
does not necessarily mean that she would label
her relationship as ‘unequal’. It is possible that the
overall division of responsibility in the family is more
equal. Nevertheless, a role division where the woman
takes much more responsibility for household duties
reflects a traditional or conservative pattern of gender
roles, regardless of whether the couple are content
with the division of responsibility or not. Our study
would show the actual effect of or association between
actual unequal division of responsibilities, rather
than the perception of ‘unequal relationship’, even if
those states probably often coincide. Only women
are included in the present study, hence the men’s
opinion or situation is not taken into consideration
here. Both men and women were included in the
original sample [19]. However, almost no men
reported that they took much more responsibility for
household duties. Actually, a previous report showed
that the men agreed on the division of responsibility;
the number of men who stated that their partner
took much more responsibility for the household
work was almost equal to the number of women who
stated that they took much more responsibility [28].
The women were also generally less satisfied with the
division of responsibility than the men were. A separate
question asked about the responsibility for daily child
care. The pattern here was similar: the women took
greater responsibility. However, the question used in
the present analyses concerns household duties only.
Still, the study has a heteronormative perspective and
focuses on women only, which may be considered a
limitation. At the same time, the aim of the study was
to explore potential effects of traditional gender roles
and unequal share of household duties between men
and women. Since it is almost exclusively the woman
who takes the largest responsibility in couples where
the division is not equal [28–30], the focus naturally
falls on the effect on women’s health and well-being,
which justifies the narrow perspective.
The choice of household duty responsibility only,
and not responsibility for child care, means a poten-
tial dilution of true associations since there may be
couples that share household duties more equally but
where the woman still takes much more responsibility
for daily child care, and hence the total general house-
hold/child responsibility is unequal towards a more
traditional gender pattern even though household
duties are more equally divided.
The cross-sectional nature of the study does not
allow for inference regarding direction of causality
between examined variables. However, there are no
reasons to believe that women who are more stressed
and in poorer health should start to take much more
responsibility at home, especially while maintaining
occupational activity and engagement. The reverse
182    F. Eek and A. Axmon
causality seems more plausible, even though of
course a bidirectional relationship is possible.
Conclusion
Previous studies have shown a persistent unequal
gender role division, also in couples where both the
man and the woman are occupationally active. The
present study indicates that such an unequal division
of responsibility for household duties may lead to
increased stress and impaired health and well-being
among women. A high share of responsibility for
household duties was also related to insufficient
time for leisure activities and relaxation, which may
contribute to an increased risk of poor health. Hence,
although an increasing employment rate among
women is valuable for both society and individuals,
it is important to work towards a greater gender
equality at home, to maintain this development
without having negative effects on women’s health
and well-being.
Conflicts of interest
None declared.
Funding
This work was supported by the Swedish Council
for Working Life and Social Research (FAS no.
2007:0083).
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