Social and economic impacts of non-communicable diseases by gender and its correlates: a literature review

Abstract

Background

Tackling social impacts derived from gender disparities is a pathway to universal health coverage (UHC). Gender intersects with other factors behind social and health inequalities, exacerbates them and influences health systems’ performance. However, there is scarcity of gender-based studies that assess the social and economic impacts of non-communicable diseases (NCDs). This study aims to identify economic and social impacts of NCDs by gender and its correlates.

Methods

Following the guidelines proposed in the Cochrane Manual for Systematic Reviews of Interventions and the PRISMA Statement, we conducted a narrative and structured literature review to identify the economic (direct medical and non-medical, and indirect costs) and social (right to health, employment, poverty, social exclusion, and others) impacts of NCDs by gender, and its structural, sociodemographic, health conditions, political and health systems correlates, for the period 2002–2022, in English and Spanish. Reviewed studies were described according to country and research context, temporal evolution, gender, impacts of NCDs and correlates.

Findings

Five thousand five hundred fifty-one publications by title and abstract were reviewed, and 185 articles were selected. There is limited evidence with gender perspective addressing the social and economic impacts of NCDs (around 10% of publications) that helps to better understand the difference in the burden of these conditions between men and women. We identified that the social burden primarily affects women in their quality of life, where gender inequities are observed in aspects such as: health care, employment status and living conditions. In addition, a greater responsibility falls on them as caregivers. On the other hand, the economic burden affects more to men, both in terms of direct medical costs and indirect costs. Among the factors that most influenced the identified impacts, we found gender, age, and socioeconomic level. We also identified that access to health insurance that offers financial protection against these conditions is essential to reduce these impacts.

Conclusions

NCDs pose a significant social and economic burden due to their impact on the health of the population, healthcare systems, and the economies of households and nations, which will likely increase over time. This impact is closely related to gender, although it has been scarcely documented. Public policies aimed at enhancing access and achieving UHC are essential to guarantee effective financial protection in health, especially for the most vulnerable sectors of the population.

Background

Tackling social impacts derived from non-communicable diseases (NCDs) is a critical challenge for the achievement of the Sustainable Development Goals (SDGs). Worldwide, NCDs are responsible for 74.0% of deaths [1], while also causing disability, pain and suffering. NCDs and their complications such as ischemic heart disease, stroke, loss of extremities, and organ damage (nephropathy, neuropathy, blindness, etc.) affect people living with one or more of these conditions, their families, and health systems [2,3,4]. Understanding and modifying the factors that influence the NCDs health-disease process is a complex task since their determinants are multifactorial [2, 5].

To adequately analyze and address the differences in vulnerability and consequences of NCDs between men and women, it is necessary to distinguish between sex and gender and their respective health effects. Sex-related differences are based on biological factors or attributes and genetic, epigenetic and hormonal influences of biological sex. They are encoded in our DNA and determine physical and physiological characteristics that relate to reproductive function, sex hormone concentrations, gene expression on the X and Y chromosomes, and their effects. Variations caused by sex differentially affect disease susceptibility and presentation, pathophysiology, clinical manifestations, disease progression, and responses to treatments, acting as modifiers of the major causes of death and morbidity [6,7,8,9].

In contrast, gender is a multidimensional social construct related to social norms and expectations within a historical and cultural context. It refers to the socially constructed roles, identities, behaviours, lifestyles, gender relations and life experiences, expressions, and identities of girls, women, boys, men, and gender-diverse people. Gender influences health-disease processes, determining how people perceive themselves and others and how they act and interact with each other [6,7,8,9].

Gender conceptual domains such as gender identity, gender roles, gender relations and institutionalized gender, related to health care are frequently ignored by health promotion efforts to prevent and mitigate NCDs [10, 11]. NCDs affect negatively individuals, households, health systems and national economies, causing productivity loss and low economic growth and development [6, 7]. These effects vary between men and women, reflecting how gender influences NCDs and perpetuates structural and power inequalities in society [11]. Therefore, gender becomes a major social determinant of health that modulates behaviors, differential exposure to risk factors, and social vulnerabilities. It also interacts with health systems’ responses [10], influencing the way men and women fall ill, seek, access and use health services and attitudes of individuals, the community and medical personnel, which are associated with differences in the use of preventive measures, the prescription of medications, health insurance reimbursement, and the referral or acceptance of specific surgical therapies, between men and women [6,7,8,9, 12, 13].

In particular, gender disparities exacerbate the negative effect of poverty as a determinant of NCDs [14, 15], imposing a huge burden of disease for both women and men, but there are important differences. The greater social and economic disadvantages that women face compared to men hinder their ability to reach their full health potential [16]. Most of the worldwide poor are women [17], with lower purchasing power to afford NCD treatment requirements. Gender roles impose caregiving responsibilities on women, reducing their opportunities for formal employment. Additionally, women have less autonomy and voice in household decisions, especially regarding health expenditures, and medical costs affect them more, leaving them with less disposable income [18].

These elements support the hypothesis that gender roles influence the seeking of health services and access to medical care, affecting diagnosis and treatment [18]. Furthermore, risk factors for NCDs are also influenced by gender-defining different levels of exposure and differentiated health damages while they interact with other social determinants [19]. Mitigating gender disparities and their intersection with health and gender-equity goals outlined in the SDGs is a critical, but not well recognized, pathway to consolidate an effective social protection system and achieve universal health coverage (UHC) [20].

The reduction of gender gaps between women and men has been a global concern since the Fourth United Nations World Conference on Women in Beijing in 1995. Nevertheless, there are no clear strategies to adopt the gender perspective as a central axis to promote gender equity in various priority areas, including health [5, 21]. The gender perspective in health implies a broader and clearer vision of the unjustified differences in health outcomes between men and women, which should help to make better interventions in different spheres, in addition to allowing the identification of gaps of information and evaluation [5, 21]. As a result, governments have been called upon to undertake deliberate policy actions that —without omitting the genetic or physiological aspects that underlie the diseases of either sex— highlight inequalities and contribute to the reduction of gender disparities in health [22].

The design of effective gender-sensitive health policies should be anchored in research that deepens our understanding of social and economic impacts of NCDs from a gender perspective [23]. However, studies that assess the impacts of gender on NCDs remain scarce. A better understanding of gender-related vulnerabilities is relevant to enhance systemwide efforts to improve the health system response, especially in low and middle-income countries (LMICs). This paper aims to present a narrative and structured literature review, for the last two decades, to identify how gender plays a role as an important mediator or determinant in the social and economic consequences attributable to NCDs.

Methods

Search strategy, inclusion criteria and study selection

Following the guidelines proposed in the Cochrane Manual for Systematic Reviews of Interventions version 6.3 [24], and the PRISMA Statement [24], we conducted a narrative and structured literature review to identify the economic and social impacts of NCDs by gender, and its structural, sociodemographic, health conditions, political and health systems correlates, from 2002 to 2022. We employed the most recognized free access digital libraries: PubMed [25], VHL-OPS [26], Elsevier Science Direct [27], Hinari-Research4Life [28], and Cochrane Library [29]. The reference results were provided by PubMed, acknowledged as the most complete tool. The search algorithms were built independently (details in Appendix 1).

The results obtained were assessed through the free access tool Rayyan [30] version 2022 (https://rayyan.ai/reviews), a web app, which facilitates the selection of publications retrieved by the search engines of digital libraries by multiple people simultaneously. This is done through a semi-automation process where it is possible to identify and eliminate duplicates, all based on the review of abstracts and titles of the published works. The selection of potential publications was made by five researchers independently, based on the title and abstract. Potential articles in full version were reviewed to identify those that could provide information on the proposed objectives and proceeded to extract data. The procedure for inclusion and exclusion of publications is described in Fig. 1. Eligible study designs included observational studies, cohort studies, case-control studies, cross-sectional studies, literature reviews, systematic reviews, economic analyses, qualitative studies, and ecological studies. Studies that estimated the impact of at least one of the NCDs of interest in women or men were included: cancers and neoplasms, cardiovascular diseases, chronic respiratory diseases (COPD or asthma), type 2 diabetes mellitus, and chronic kidney disease in at least one of the considered social or economic impact measures (see Appendix 1). Only studies published between 2002 and 2022 were included, with no age restrictions for the participating individuals, in English or Spanish. Potential publications were defined as those that included the outcomes of interest. Studies that addressed populations with other types of conditions, such as congenital; that had another type of outcome (clinical, association with risk factors) or other types of publications such as research protocols, editorial letters, opinion articles, clinical practice guidelines, and preclinical trials) were not included.

Fig. 1

PRISMA flowchart. Source: Elaboration based on the information extracted

Data extraction

We recorded the following variables: country, year of publication, type of impact (social or economic), gender perspective (dichotomous: yes or no), correlates (health system, social and political) that influence the identified impacts, as well as in those who observed greater vulnerability experienced. We considered a study with a gender perspective if it explicitly analyzed how social and cultural differences between genders influence a phenomenon (social or economic), recognizing that the experiences of women and men are determined not only by biology but also by social constructs [31]. Specifically, we identified those publications that, from the approach, results and conclusions, emphasized gender as one of the most relevant aspects in the impact of NCDs, where a definition of gender as a social construct was first made. We described the selected publications according to country and research context, temporal evolution of the cumulative number, gender, NCDs impact dimensions and its correlates.

The protocol of this study was approved by the Research, Ethics, and Biosecurity Committees of the National Institute of Public Health of Mexico (ID: CI-507–2022/CB22-173).

Results

General characteristics of the included studies

After reviewing the title and abstract of 5,551 identified publications, we selected 185 for extensive review (Fig. 1), of which just 12% (22 en total) incorporated the gender perspective, with the majority using sex as a synonym for gender (Table 1). 45.4% of the studies were cross-sectional analyses, 15.7% were cohort studies and the remaining 38.9% were observational studies, economic analysis studies, systematic reviews, among others.

Table 1 Characteristics of the publications included in the qualitative synthesis

95% of the publications reviewed addressed only one NCD. 59.5% dealt with a neoplasm, 14.6% with cardiovascular diseases, and 12% with type 2 diabetes. Regarding neoplasms, 36.6% of the investigations dealt with breast cancer, 28% with cancer in general (without specifying any), 9.3% with cervical cancer, 5.6% with lung cancer, 4.7% with prostate cancer and the remaining 18.8% with others. Breast and cervical cancer were the most investigated in the case of women, while lung and prostate cancers were the most investigated in men.

According to sex, 63.2% of the studies reviewed in full analyzed both sexes, 28.6% only women, 1% men, and the rest were not reported because they were review articles with an ecological analysis. Regarding age, 67.6% included persons aged 18 years and over, 11.4% included all ages, and 10.8% did not report a specific age range. However, they described it as an adult population, 7% did not report such data, and the rest were age ranges other than those mentioned above.

By world region, 47.6% of the reviewed studies were conducted in North America, 21.6% in Asia, 20.5% in Europe, and 4.9% from Latin America (Fig. 2). We also observed a remarkable growth in the cumulative number of publications from the second decade analyzed, with a predominance (in amount and increase) of women over men (Fig. 3).

Fig. 2

Mapping of included publications in the qualitative synthesis by country and research context. Source: Elaboration based on the information extracted

Fig. 3

Evolution of cumulative number of publications according to gender. Source: Elaboration based on the information extracted. ncr: no cases reported

Measures of social or economic impact

Of the articles selected, 65.4% addressed economic impacts (49.7% direct medical costs, 13% indirect costs, and 2.7% direct non-medical expenses). In comparison, the remaining (34.6%) addressed social impacts (10.3% impacts on quality of life, 7.6% on gender inequality, 4.9% right to health, 8.1% quality and level of employment, and 4.3% on poverty, support networks and social exclusion) (Fig. 4).

Fig. 4

Distribution of reviewed publications according NCDs impact dimensions. Source: Elaboration based on the information extracted. ncr: no cases reported

Excluding the review studies (n = 17), of those focused on women (n = 53), 62.3% addressed economic impacts (highlighting direct medical costs (49.1%) and indirect costs (13.2%)), and 37.7% social impacts (13.2% impacts on quality of life, 3.8% right to health, 7.5% quality and level of employment, and 5.7% poverty, support networks and social exclusion) (Fig. 5). Of the four studies on men, three addressed economic impacts (2 direct medical costs and one indirect cost), and 1 addressed social impacts on poverty. Of the studies focused on both sexes (111), 68.5% addressed economic impacts (54.1% direct medical costs, 12.6% indirect costs, and 1.9% direct non-medical costs), and 31.5% social impacts (9% impacts on quality of life, 6.3% right to health, 7.2% gender inequality, 6.3% quality and level of employment, and 2.7% poverty and support networks) (Fig. 5).

Fig. 5

NCD impacts between men and women. Source: Elaboration based on the information extracted

Seventy-five publications (40.5%) identified gender as the primary determinant of economic impacts, highlighting the differences in employment status between men and women, influencing the income received, access to insurance and health services for diagnosing and treating NCDs. Of the 22 studies with a gender perspective identified, 18 (82%) identified gender as the factor with the most significant social impact, while the remaining 4 highlighted its economic consequences.

Regarding the factors associated to the impacts of NCDs, 97.8% of the studies focus on those related to sociodemographic factors and health and health system conditions (Fig. 6). Regarding the former, 82.2% focused on categories such as age, socioeconomic level, educational level, area of residence, the existence of complications, comorbidities, type and stage of cancer, and others. In 15.7% of the studies, factors related to the health system were identified (i.e., access to and type of health insurance, access to health services, or quality of health care). The three studies on public health policy analyzed public spending on paid parental leave, job training for men, and public employment services for women [32], as well as financial protection in health [33, 34].

Fig. 6

Correlates of NCDs impacts. Source: Elaboration based on the information extracted

Discussion

This review study identifies the main social and economic consequences associated with NCDs, highlighting mainly the role of gender as a social construct and mediator of these consequences. Despite the notable increase in the cumulative number of publications from the second decade analyzed, with a predominance of women over men, we identified few published studies (just over 10%) that, from a gender perspective, addressed the social and economic health impacts of NCDs, as well as their correlates, which contributes to making invisible the multiple social vulnerabilities experienced, above all, by women.

The health, social and economic impacts of NCDs were mainly associated with malignant neoplasms and breast cancer, with a predominance of studies for North America, mostly in the United States. Among the health and social impacts primarily observed in women, there were reports of effects on quality of life, morbidity and working conditions. Some studies point to the “sacrifice” of work, education, and care and treatment of NCDs experienced by women in the face of budgetary restrictions to meet other household needs and even the care of men with NCDs. In this regard, the approach of integrating evidence coming from social and biological disciplines proposed by Rieker and Bird [35] could offer new perspectives for research, by formulating that the convergence of social and biological factors greatly influences the differences in health between men and women. Regarding sexual/biological factors, they raise several conjectures related to hormonal and physiological issues of natural selection on survival [35]. However, the present review focused on the role of gender, understood as a social construct within a specific historical and cultural context, as a mediator in the consequences of NCDs on population health, the health system, the household economy and the macroeconomy, and we did not highlight biological aspects that may explain these consequences.

With respect to health-related consequences, the evidence showed that men tend to present more chronic diseases with premature deaths. In contrast, women have a longer life expectancy and higher morbidity (due to disease and disability, in addition to a decrease in quality of life as they age). Gender differences can explain this paradox. Social factors, which were expressed in a gender-differentiated manner, focus on access to protective resources such as income or education, labor benefits (health insurance, pensions, or retirement), and other risk factors or behaviors that vary according to gender can influence exposure and health impacts. Regarding this, some authors suggest developing models that address how the gender and health paradox differs from socioeconomic and racial/ethnic health disparities based on the determinants of health, in order to explain how social differences between men and women (gender binary) influence or exacerbate health disparities. These models should allow for a more holistic analysis to achieve a better understanding of how these factors interact, thereby enabling the creation of public policies more suited to the specific health needs of each location or region [35].

The health and social impacts of NCDs, such as loss of quality of life, morbidity, mortality, and life expectancy, affect both the microeconomic level (individuals and households) and the macroeconomic level (healthcare systems and the national economy) [36]. At the household level, these impacts depend on the perceived illness and the pursuit of treatment, generating direct costs (hospitalization, medications, transportation, lodging, food) and indirect costs (caregivers’ time, loss of productivity). The lack of medical care can also cause similar indirect costs. To cope with these costs, households adopt strategies such as substituting labor, using savings, changing consumption patterns, or selling assets, which can lead to poverty and loss of well-being [37].

Regarding economic impacts, most of the studies reviewed (65.4%) quantified direct costs, primarily medical costs and, to a much lesser extent, non-medical costs, while the minority focused on estimating indirect costs derived from productivity losses (lost wages) related to NCD complications, such as morbidity, disability, retirement or early retirement, as well as premature deaths, which demonstrates the need for studies of greater scope and impact of these types of conditions [35]. A more significant burden of direct medical costs was identified for men, especially in relation to buying drugs and payment of treatment and hospitalization services for neoplasms, as well as more significant catastrophic health expenditure in women during the diagnostic and terminal phases of cancer. Despite the heterogeneity in the contexts of the studies reviewed, the results are congruent with those observed in other studies focused on the economic impacts of NCDs, which suggest that people from low- and middle-income households are those with a considerable negative effect [38,39,40,41,42], especially those headed by women [39]. In addition, it has been widely documented that women are at a great disadvantage in terms of financial resources to cover the costs of medical care, mainly due to the female work pattern, which assigns them the primary responsibility for household work (socially devalued), with few opportunities to participate in the labor market. This situation is detrimental not only to their ability to pay for the purchase of medical services but also to the possibility of contracting contributory insurance options, public or private, to meet their health needs [19].

The NCDs affect the economic stability of families, especially in LMICs. The lack of medical insurance and social safety nets can lead to catastrophic health expenses, pushing households into poverty [36, 37]. In Kenya for instance, NCDs have reduced 28.6% the family income [43], with more than 1.5 million people falling into poverty because of the high costs of healthcare services, without any health insurance very frequently [44]. Studies on the impact of NCDs on households indicate that men and women experience a reduction in income of 20.1% and 15.2% respectively [45], due to lower labor force participation among women and reduced income for men due to lower labor force participation and hourly wages, while women reduce their working hours, and differences in the type of employment.

Regarding the consequences of NCDs on the health care system, the reviewed studies suggest a constant increase in the healthcare expenditure related with NCDs [37], which further strains public budgets. This increase is due to population aging, higher expenses due to age, and growing demand for technologies to address NCDs worldwide [46]. The rapid increase of these diseases has tested human resources, equipment, and healthcare infrastructure, generating greater demand for services [47]. This financial pressure is notable in LMICs, where funds do not grow in line with the needs for NCD-related care [36, 44]. These consequences are expressed differentially between men and women, and actions are required in the health system to address them. These actions include strengthening the capacity of healthcare providers to identify and respond to gender-related issues in the supply of health services and programs so that they respond to the health needs of men and women with gender-sensitive guidelines and protocols and support their implementation [13, 48]. Additionally, specific barriers to the use of NCD prevention and treatment services by men and women, including cultural norms that affect healthcare-seeking and treatment behaviors among men, women, boys, and girls in the community, need to be identified to design strategies aimed at reducing gender-associated disparities in access to and use of health services, addressing the specific disadvantages that women and girls tend to face that make them less likely to access NCD services in certain communities, such as lack of decision-making power and their economic inability to access and benefit from public health policy efforts in the prevention and treatment of NCDs [13, 48].

The studies also reveal that NCDs have serious long-term repercussions on the economy, causing income losses, reduced investment opportunities, and weaker social and economic development, especially in LMICs [49, 50]. It is estimated that these diseases undermine economic development with losses exceeding $600 billion in national income [37]. Furthermore, NCDs have a negative impact on production, productivity, and social well-being, affecting both household economies and macroeconomics [51]. Figure 7 summarizes the consequences of NCDs on health, the healthcare system, household economy, and macroeconomics [36, 37, 44, 45, 47, 49, 51,52,53].

Fig. 7

Summary of consequences of NCDs on health, the health system, household economy, and macroeconomy. Source: Elaboration based on the reviewed literature [36, 44, 45, 47, 49,50,51,52, 54, 55]

The correlates of the impacts identified were mainly social, especially in women. The predominance of proximal determinants such as individual risk factors related to baseline morbidities, age, genetic load, sex, and ethnicity was notable as a starting point to provide an explanation or a possible relationship of these with the impacts of interest of NCDs. Only three of the 185 publications selected included aspects related to structural factors: public policy and the level of public health.

Our study should be interpreted considering the following limitations. First, regarding “advanced search engines”, only the PubMed search engine has the options and filters for an adequate construction of the search algorithms. Second, the search was limited to a certain period. Third, only articles in two languages were included, which could have influenced those aspects where we had few results, such as the gender perspective. Fourth, gender impacts on NCDs have been scarcely documented.

This study offers three lessons for LMICs: First, our findings confirm that gender exacerbates negative consequences in health outcomes and therefore gender-sensitive health interventions should be implemented to prevent health harms that are caused or exacerbated by gender. Second, there is a clear disparity in research focusing on only one sex or gender, since most of the single-sex studies are dedicated to women. This implies an urgent call for new studies to disaggregate health outcomes by gender and to fund studies on gender-specific diseases and conditions, both for women and for men. Gender-focused research could inform better design of health interventions. Third, health insurance that offers financial protection against health problems is essential to reduce negative impacts and disparities exacerbated by gender. Promoting UHC could assist in achieving other SDGs, considering that health insurance coverage is helpful to avoid impoverishing health expenditure for people living with NCDs and that this mechanism creates social solidarity.

In sum, NCDs represent a significant social and economic burden due to their impact on population health, healthcare systems, and household and national economies, which is likely to increase over time. This impact is closely related to gender, although studies addressing these differences between men and women are still scarce. Public policies aimed to enhance access and UHC are essential to guarantee effective financial protection in health, especially for the most vulnerable sectors of the population.