We found that a higher proportion of women reported poor health compared to men, a finding in line with studies from other developing countries (Pakistan, Bangladesh) and countries in transition (Ukraine) [15
]. Macintyre et al., reported from Britain that the pattern of gender differences in health outcomes (including SRH) is highly complex and varies across the life course [21
]. This potentially explains why the female disadvantage has not been found in some countries [22
]. The same authors reported that a female excess in psychological distress was consistently apparent across the life course. Low psychological well-being is associated with poorer SRH [24
]. Evidence from Aleppo suggest that mental distress is common in low income women [25
], and that anxiety and depression are is more prevalent among women than men [1
]. This also may explain why women who have some social support were less likely to report poor SRH compared to men.
We found age to be a significant predictor of poor SHR in both men and women in Aleppo. Evidence from other countries shows that gender differences in SRH are age dependent [21
Our findings suggest that being married is an important predictor of poor SRH in women. Married women were more likely to report poor health than unmarried women and more than twice as likely as married men to report poor SRH. Whilst our survey does not provide direct explanation for this discrepancy, it is reasonable to assume that this may have its roots in gender roles and traditions of the Syrian society. Married women bear the burden of household duties and child care whilst at the same time having less opportunity to do recreational activities. Such burden may be less pronounced among better off families, which may explain why socioeconomic status was a more important predictor of SRH in women compared to men. Women in the higher socio-economic group were more than three times less likely to report poor health compared to those in the lower socio-economic group. Still, this is an assumption that warranted further research.
Gender roles and societal traditions may also reflect on the observed association between obesity and physical activity with SRH. High BMI scores showed a significant association with poor SRH in both men and women, however, the effect did not reach statistical significance when adjusting for other covariates. Ferraro et al. reported that people with a BMI of more than 30.5 reported poorer rating of health than those with normal or below normal weight even after controlling for a number of indicators of ill health and physical functioning [27
]. A recent study on obesity in Aleppo showed that obesity was higher in women than in men (46.3% vs. 28.4%, P < 0.001) with the highest prevalence being in the older age group (46–65) [4
]. Currently obesity is not stigmatized in Syria as in western nations. On the contrary, many sections of Syrian society still see obesity as a sign of prosperity.
In Aleppo, half of the women but only one fifth of men reported low levels of physical activity [4
]. This is likely to be due to physical activity being more feasible for men than women in a generally conservative society. This may also explain why lack of physical activity was more strongly associated with poor SRH in men than in women, since certain recreational activities may not be an option for many women in the Syrian society. The finding in men is in line with evidence showing that sports participants reported better SRH than non sports participants [28
In our study, smoking was associated with poor SRH among men, but not among women. Findings from other studies suggested an independent association between smoking and SRH with never smokers rating their health best [14
]. Smoking in Syria, like in many Arab countries, is traditionally a male activity [3
]. Cigarette smoking among men has recently reached very high proportions, with 51% of adult men in Aleppo being daily smokers [3
]. Men daily smokers in Syria consume on average twice as women [3
], which can help explain the predominance of reporting poor SRH by male smokers.
This study is not without limitations. First, the cross sectional nature of the data limited our ability to understand causal mechanisms that result in poor SRH in men and women. For example, it was not clear whether low psychological wellbeing among women results in poorer SRH or whether poor health outcomes result in a higher level of depressive symptoms in females. Second, increased gender disparity of poor SRH in the older ages in our study may result from confounding introduced by what is termed 'mortality selection', especially at older ages [19
]. Adult men have higher age-specific mortality rates than females in most societies. The highest degree of confounding usually occurs at older ages where mortality rates among males are higher than those of females thus leaving a group of men who are healthier than their female counterparts [19
Despite these limitations, our study is the first in an Arab country to report on SRH and its determinants in men and women. We have interpreted the findings in light of previous research on smoking and obesity as well as our understanding of the unique attributes of the Syrian society and culturally shaped gender roles. There is evidence that self ratings of health and morbidity are influenced by differences in expectation, perception, social experience and comparison all of which may vary throughout time but are culturally shaped [26
]. We suggest that further qualitative and quantitative studies are needed in Arab country in order to provide a fuller understanding of the mechanisms that result in poor SRH in men and women in Syria and alike societies.
What this paper adds
• This study is the first in an Arab country to report on SRH and its determinants in men and women.
• The findings strongly support evidence from other developing countries which shows that females are much more likely than males to report poor SRH.
• Our findings suggest that certain determinants of SRH (i.e. marital status, physical activity, social support) may be culturally shaped in that they reflect specific gender roles and social norms and expectations.
Women are particularly prone to reporting poor SRH, which can reflect subtle societal traits related to prevailing norms and gender roles. In-depth studies are needed to provide a fuller understanding of what appears to be culturally influenced determinants of SRH. This is important when designing and delivering culturally sensitive and effective interventions in Syria and similar Arab societies